Form Oc-401.1 - Initial Application For License To Appear On Behalf Of Claimant printable pdf download

Form Oc-401.1 - Initial Application For License To Appear On Behalf Of Claimant

State of New York

WORKERS' COMPENSATION BOARD

INITIAL APPLICATION FOR LICENSE TO APPEAR ON BEHALF OF CLAIMANT

under Section 24-a of the Workers' Compensation Law & Rules with respect to granting

Licenses to Representatives of Claimants. CHECK ONE: q With Fee

q Without Fee

Applicants failure to disclose fully and accurately any fact or information called for by any question

may result in the denial of the application for a license, or, if applicant shall have been licensed

before the discovery thereof, in the revocation of his/her license.

1. Name (first, middle, last)_______________________________________________________________

Have you ever been known by any other name?

q Yes q No

If yes, state other name(s):

__________________________________________________________________________________

2. Home address(es) during past five years (enter present address first):

Street, City, State

From

Home Telephone Number (_______) __________________________

3. Business or Occupation during past 5 years (including self-employment). Give present business first:

From

Employer

Address

Salary

Telephone No. during regular business hours (_____) _____________ Fax No.: (_____) _____________

4. Which address and telephone number would you prefer to have appear on the Board's list of

licensed representatives? (Check one only) q Residence

q Business

5. Social Security No.___________________ Federal Employer ID No. (if any)______________________

(See Privacy Notification on Page 4. If you have neither number, explain on Page 4.)

6. Citizenship: q United States of America

q Other________________________________________

If naturalized, give date and place of naturalization__________________________________________

If permanent resident alien, give registration no. and date ____________________________________

7. Are you over 18 years of age? q Yes

q No

8. What special training or experience has, in your opinion, particularly qualified you to appear on behalf of

claimants before the Workers' Compensation Board? _______________________________________

__________________________________________________________________________________

OC-401.1 (9-07) Page 1

Form Oc-401.1 - Initial Application For License To Appear On Behalf Of Claimant