Workers Compensation Complying Agreement Form

The “HEARING CANCELLATION REQUEST” form must be completed by each party of an application or its agent who wishes to cancel an informal or pre-formed hearing previously scheduled before a Workers` Compensation Commissioner. [NOTE: Full information on the location of workers` rights designated by the employer is contained in Memorandum No. 2017-08] The Workers` Compensation Board does not accept an applicant`s electronic signature on the forms prescribed by the Commission because the Commission is unable to effectively assess the electronic signature procedure used by a carrier, medical service provider, lawyer or authorized agent to ensure that the procedure complies with the New York Electronic Signatures and Records Act (ESRA) and applicable rules. Therefore, an applicant`s free-hand signature must be submitted when an applicant`s signature is required by law, including the forms OC-110a, OC-400, OC-400.1, C-300.5 and C-32. There is no need to file the workers` returns by exempt workers. If the form you are looking for is not mentioned above or in the General Forms list, please email the form section of the card. The “RECORD OF EMPLOYMENT CONTACTS” form (extracted from the information file below) can be used by an employee to report contact with employers during a job search, while the employee is compensated. Here is a list of all the workers` Compensation Board`s mandatory forms [NOTE: Read Form 6B, 6B-1 and 75 directions (above) for the full instructions for filing this form.] Within a 7-day schedule, we will also provide information on all payments to which you are entitled if you need free time, if you have shorter work schedules or if you need medical, hospital or rehabilitation services. The “STIPULATION APPROVAL PROCEDURE” form is a simple backgrounder describing the procedures for requesting a hearing of the stipulation (including actions taken by an applicant or a-state) and describing what happens during a scholarship hearing. They are required to respond to EML`s requests for information within seven days. If you don`t respond in time, EML can pay your weekly payments. If you need help filling out these forms, please contact your WCB district office on site. Form 98 “MANDATORY NOTICE TO DEPENDENTS BY EMPLOYER OR INSURER TO BE FILED UPON DEATH OF EMPLOYEE WHO IS RECEIVING WEEKLY DISABILITY BENEFITS” must be completed by an employer or insurance agency for its workers` compensation insurance to inform survivors of a deceased worker of their potential entitlement to benefits for dependents under the Worker`s Compensation Act.

E-mail: Download the People Submission Form (PDF) and send an email to [NOTE: this form is only accepted in stock green.] The forms are in PDF format.