Form Oc-401.1 - Initial Application For License To Appear On Behalf Of Claimant (Page 3 of 4) in pdf

Form Oc-401.1 - Initial Application For License To Appear On Behalf Of Claimant Page 3

17. Name five character references, in the following fields, who have known you for at least five years.

(Name only persons who have had a reasonable opportunity to form an opinion of your character,

competence, and integrity during the period of acquaintance indicated.)

Field

Name

Address

No. of Years

Business

Professional

Social

Family Life

and

Neighborhood

18. Approximately how many claims, if any, have you handled before the Workers' Compensation Board

(WC Law Judges and Board Panels) during the last completed calendar year? ____________________

State of New York

)

ss:

County of ________________________)

________________________________________________, being duly sworn, deposes and says that I am

the applicant; that I have duly read and signed the foregoing application; that all the matters contained

herein are true, excepting as to such matters therein stated to be alleged on information and belief and

those matters I believe to be true. In addition, I hereby authorize duly designated employees of the

Workers' Compensation Board to make inquiry into and obtain disclosure of any information required to

obtain verification of any statement made in this application.

____________________________________________

Signature of Applicant

Sworn to before me this

________day of _______________ 20____

NOTARY'S STAMP

___________________________________

Notary Public

Applicants Without Fee: Secure and attach to this application the following documents:

Copy of resolution of organization designating you as its duly authorized representative as

provided for under Section 24-a of the Workers' Compensation Law and the Rules with respect

to granting licenses to representatives of claimants, setting forth basis of remuneration or

salary to be paid to you.

A certification to such resolution, executed by the President and Secretary of said

organization together with the seal of said organization.

OC-401.1 (9-07) Page 3

Form Oc-401.1 - Initial Application For License To Appear On Behalf Of Claimant Page 3