Form Rb-89.2 - Cover Sheet - Application For Reconsideration / Full Board Review

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STATE OF NEW YORK

WORKERS' COMPENSATION BOARD

PO Box 5205 - Binghamton, NY 13902-5205

COVER SHEET - APPLICATION FOR RECONSIDERATION / FULL BOARD REVIEW

WCB Case Number(s)

Carrier Case Number(s)

Date of Injury

Carrier Code

Carrier's Name

Claimant's Name

Address

TO THE APPLICANT: This Application for Reconsideration / Full 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 the Board address listed at the top of

this page. A copy of this Application must be served on all parties in interest within 30 days after notice of the filing of the Board panel's decision with the Secretary of the

Board. 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.

1. This application is made on behalf of:

Claimant

Employer/Carrier

Special Funds

Uninsured Employers' Fund

(name)

Attorney/Licensed Representative

2. The filing date of the Memorandum of Decision by the Board Panel is

3. This application for Reconsideration / Full Board Review under WCL § § 23 and 142[2] is:

Mandatory (there was a dissent other than the sole basis

of which is referral to an impartial specialist)

Discretionary

4. The remedy sought is:

Administrative Correction of the Memordandum of Decision

Modification of the Memorandum of Decision

Reversal of the Memorandum of Decision

Rescission of the Memorandum of Decision

5. This case is presently (check one):

Disallowed

Established

6. Specify the issue(s) for review:

Employer/employee relationship

Average Weekly Wage

Special Funds Liability

Accident

Authorization of Treatment

Attorney/Licensed Representative Fee

Occupational Disease

Period of Disability

Facial Award

Notice

Degree of Disability

Section 32 Denial

Causal Relationship

Reimbursement

Disability Benefits

Death Benefits

Penalty

Discrimination

Timely Claim Filing

WCL § 114-a Disqualification

Policy Coverage

Jurisdiction

Apportionment

ATF Deposit

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:

THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

RB-89.2 (1-11)