Form Rb-89.3 - Cover Sheet - Rebuttal Of Application For Reconsideration / Full Board Review

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STATE OF NEW YORK

WORKERS' COMPENSATION BOARD

NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205

COVER SHEET - REBUTTAL OF 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 SENDER: This Rebuttal of an 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 Rebuttal 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 Rebuttal.

1. This rebuttal is made on behalf of:

Claimant

Employer/Carrier

Special Funds

Uninsured Employers' Fund

(name)

2. This rebuttal is in response to an application for:

Mandatory Full Board Review

(choose only one)

Discretionary Full Board Review

3. The application was served upon the above cited party on:

4. The filing date of the Memorandum of Decision which is the subject of the application for Reconsideration / Full Board Review is:

5. This rebuttal contends that the:

Application for Reconsideration / Full Board Review should be denied.

Memorandum of Decision should be administratively corrected to read:

Memorandum of Decision should be affirmed in its entirety

Memorandum of Decision should be modified as to:

6. As to the finding(s) of fact and/or conclusion(s) of law made in the decision, this rebuttal contends:

7. Does the record cited in the application constitute the full record for review?:

Yes

If Yes, do you rest on that record?:

Yes

If No, and you contend that the record cited in the application does not constitute the full record for review, provide below the additional hearings,

documents, and transcripts in the WCB's electronic file that are relevant to the issue(s) and ground(s) raised in the application, were not cited on the

application, and complete the record for review:

Hearings: provide date(s) where issue(s) was raised before the Workers' Compensation Law Judge and evidence presented

pertaining to the issue(s) and ground(s) raised and document ID number if applicable. If hearing minutes have not been transcribed,

so indicate:

Documents: provide name and document ID number:

THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES

RB-89.3 (1-11)

PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION