Form Rb 89 – Fill Out and Use This PDF

STATE OF NEW YORK

WORKERS' COMPENSATION BOARD

PO Box 5205 - Binghamton, NY 13902-5205

COVER SHEET - APPLICATION FOR BOARD REVIEW

TO THE APPLICANT: This Application for Board Review may be filed with the Board by fax (1-877-533-0337; see Subject No. 046-144), e-mail (wcbclaimsfiling@wcb.ny. gov); see Subject Nos. 046-144 and 046-375), personal delivery to a Board District Office, or by mailing to one of the Board addresses listed at the top of this page. A copy of this Application must be served on all parties in interest. Sections 1 and 2 on the reverse side of this form must be completed. The failure to supply all information requested by this form may result in dismissal of the Application. If an additional attorney fee is being requested, Form OC-400.1 must be attached and served on all parties. For Applications filed by a carrier, TPA or self-insured employer, an up-to-date Form C-8/8.6 must be attached and served on all parties.

TO ALL OTHER PARTIES: Any Rebuttal to this Application must be served on the Board within 30 days following the date on which the Application was served on the parties, as specified in Section 2 on the reverse side of this form.

3. The filing date of the decision which is the subject of this application is:

4. The remedy sought is:	Administrative Correction of Decision	Modification of the Decision
	Reversal of the Decision	Rescission of the Decision

7. Specify the grounds for review (foundation, basis, or points) relied upon in raising the issues identified above.

8.Make reference to the record below, or such part thereof, as is relevant to the issue(s) and ground(s) raised in this application. Also, indicate when and where such issue(s) and ground(s) were raised before the Workers' Compensation Law Judge.

Hearings (if minutes are not transcribed, so indicate):

Documents: provide name and document ID number:

Transcripts: provide date and document ID number:

Non-Scanable Evidence or Videotape (WMV or AVI format only): provide description:

9.List the following period(s) and/or medical benefits awarded which will be withheld pending this application:

10.A Form OC-400.1 for an increased attorney's fee that has been properly served has been included with this application for consideration by the Board.

Certification: By signing this document in the space provided below, I certify that this application has a good faith basis in law and fact, has been instituted with reasonable grounds, and has been served upon all parties at the addresses listed in the affirmation or affidavit of service below. I understand that the Workers' Compensation Law provides for substantial penalties for instituting or continuing proceedings without reasonable grounds and/or for the purpose of delay. I understand that if this application is withdrawn for any reason or if any of the issues raised are resolved by the parties, I must immediately notify the Board and the parties served in writing.

Signature of Person Preparing Form									Date ______/______/______
Print Name				Title				Phone Number (______)______________
Address
SECTION 1
					AFFIRMATION

STATE OF NEW YORK, COUNTY OF ________________ ss: I, the undersigned, am an attorney duly admitted to the practice of law in the courts of the

state of New York. I hereby certify that I have complied with the filing and service requirements for this Application for Board Review in the manner described in Section 2 below.

I affirm that the foregoing statements are true under penalties of perjury.

Dated ______________________ Signature _______________________________________________________

Signer's Name (Print) ______________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

AFFIDAVIT

STATE OF NEW YORK, COUNTY OF ________________ ss: I, _______________________________________________________, being duly sworn,

say: I am over 18 years of age. I hereby certify that I have complied with the filing and service requirements for this Application for Board Review in the

manner described in Section 2 below.
Sworn to before me on _________________	Signature ___________________________________________________________
____________________________________	Signer's Name (Print) _________________________________________________
Notary Public

SECTION 2

A. Method by which Application was Filed with the Board (Check One):

Fax (1-877-533-0337)

E-Mail (wcbclaimsfiling@wcb.ny.gov)

Mail (specify date below)

Personal Delivery (specify date below)

Date of Mailing: __________________________

Date of Personal Delivery:____________________________

B. Method of Service on the Parties (Check One):

Mail

Personal Delivery

Specify Date of Mailing or Personal Delivery ____________________________

C. Names and addresses of all Parties Served: (Attach additional sheets if necessary.)

RB-89 (1-11) Reverse