Claims Kit

Reporting of Claim by Employer WCL 110 310.1

All injuries other than minor injuries must be reported to the Board and insurance carrier within 10 days. Failure to file within 10 days after the accident is a misdemeanor and punishable by a fine. In addition, the Board may impose a penalty of up to $2,500 

When completing Form C-2F, it is important to remember that statements may be legally binding. The employer should note on the form if they believe the claim to be questionable or fraudulent. The insurance carrier can be contacted for assistance with completing the form. Form C-2F can be filed by a third-party designated by the employer, however the employer is ultimately responsible for ensuring it is filed.

Filing Form C-2F is not necessarily an admission that you agree with the facts of a reported accident. It is a statement that an employee reported a work-related injury or illness to the employer.

Minor Injuries

The injury is minor if

• it requires two or fewer treatments by a person rendering first aid, and
• lost time amounts to less than one day beyond the end of the working shift on which the accident occurred.

For minor injuries, the employer may choose to pay for the first aid treatments directly. In this instance, the employer completes the Employer's First Report of Work-Related Injury/Illness (Form C-2F), but does not send it to the Board or the insurance carrier. Instead, the employer maintains the form in their files for the statutory 18-year period (WCL 110). Form C-2F is available from the insurance carrier, or any Board office.

Board Rule 300.37 calls for employers to distribute a "Claimant Information Packet" to workers at the time of their injury or illness.

The Board has incorporated those items in a document which, when combined with Form C-3, Employee's Claim, and Form C-3.3, Limited Release of Health Information (HIPAA), constitutes the Claimant Information Packet. Employers can comply with Board Rule 300.37 by distributing the Packet to their workers when they become aware of any injury or work-related illness.

Injured On The Job Pamphlet

While not mentioned in Board Rule 300.37, the Board's Injured on the Job pamphlet was also revised. This document, directed toward claimants, has long been used by workers' compensation stakeholders. It contains helpful details about accessing benefits and the claimant's rights within the New York workers' compensation system. Employers and carriers may distribute the Injured on the Job pamphlet to workers in addition to the mandatory Claimant Information Packet.

Employer's statement of wage earnings Form C-240

Posting Requirements  WCL 51

Every employer must post in a conspicuous place a notice, (Form C-105)  Notice of Compliance - Workers' Compensation Law,  that the employer has obtained workers' compensation coverage for their employees. The C-105 form informs employees that their employer is in compliance with the Workers' Compensation Law and of their rights and obligations if they suffer a work related injury or occupational disease. For employers who own or operate horse-drawn or automotive vehicles the notice prescribed by the Board to be posted is the C-105.1 form.

Forms C-105 and C-105.1 are not available online.

Employers obtain the C-105 or C-105.1 forms from the insurance carrier that provides coverage.

Carriers, their licensed agents, and Self-Insured Employers may email the Board at Certificates@wcb.ny.gov to obtain controlled forms not available on the website.

An employer who fails to post the C-105 conspicuously about the employer's place of business will be fined up to $250. 

Filing Deadline Approaching for Those Infected Early in the Pandemic Januasry 27, 2022

Those with a work-related injury or illness have two years from the date of becoming injured or ill to file a workers’ compensation claim, so the deadline is approaching for workers who contracted COVID-19 due to their employment in the early days of the pandemic. Filing a claim is important because workers’ compensation benefits in an established claim include lifetime medical care for the treatment of the work-related injury or illness. Even workers who have had a good outcome after COVID-19 can file a claim to protect their future rights to these medical benefits, should they ever need them. Workers should know that while not all claims will be accepted, there is no risk or harm in filing a claim, even if it ends up getting denied.

The Workers' Compensation Board does not normally accept a claimant's electronic signature on Board-prescribed forms. Due to recent increases in COVID-19 infection rates across New York State, however, as of August 16, 2021, the Emergency Relief from Signature Requirements on Listed Documents will remain in effect until further notice for the forms specifically listed in the Board's announcement:Emergency Relief from Original Signature Requirements on Listed Documents.

The Board, as standard practice, does not accept electronic signatures on Board-prescribed forms, as the Board is unable to efficiently evaluate the electronic signature process used by an insurer, health care provider, attorney, or licensed representative to ensure that the procedure complies with the New York Electronic Signatures and Records Act (ESRA) and applicable regulations. Therefore, a claimant's ink signature must be supplied when a claimant's signature is required by law.

Recognizing that workers’ compensation will be a lifeline to many workers who are affected by COVID-19, Chair Rodriguez issued a letter to insurance carriers and payers of workers’ compensation. The letter encourages payers to proactively provide information to first responders, other front-line employees and policy holders on how to file a claim; reinforce with employers that discrimination against those who file claims is illegal; conduct speedy investigations into claims; and in situations where they aren’t sure if a claim is compensable, consider issuing a payment without initially accepting liability (using WCL § 21-a), rather than disputing the claim.

Speeding up the resolution process for COVID-19 claims

Dear Claims Administrator –

Your prompt action is needed to ensure that COVID-19 claims are resolved in a timely manner, to ensure individuals with a workplace illness receive prompt and proper medical care and indemnity benefits.

The NYS Workers’ Compensation Board (Board) is requesting your immediate assistance to speed up the resolution process for COVID-19 claims when a notice of controversy has been filed. As you may know, the Board promptly schedules pre-hearing conferences for controverted cases. When a claim has medical documentation on file, the pre-hearing conference is typically held within 30 days of receipt of the notice. Scheduling a pre-hearing conference may be delayed if the Board does not have medical documentation on file.

For COVID-19 claims, the Board is not receiving the timely medical documentation required in order to establish a claim, and we need your help in doing so. For all open COVID-19 claims, please complete your review of your claims systems and send the requested documentation to the Board no later than September 25, 2020.

• For COVID-19 claims where you have filed a notice of controversy (FROI-04 or SROI-04 transaction in eClaims), but do not have medical documentation in your case files, please contact the injured worker and request that they send you and the Board copies of COVID-19 related medical documents.Documents may be emailed to wcbclaimsfiling@wcb.ny.gov (preferred) or mailed to:

NYS Workers' Compensation Board
Centralized Mailing Address
PO Box 5205
Binghamton, NY 13902-520

• For COVID-19 claims where you have filed a notice of controversy (FROI-04 or SROI-04 transaction in eClaims), have medical documentation on file but medical documents have not been uploaded to eCase, please send such documentation to the Board at: wcbclaimsfiling@wcb.ny.gov. You can request a listing of all controverted COVID-19 claim case numbers for which the Board currently has no medical documentation by emailing datarequests@wcb.ny.gov. Please provide your W-number and contact information including your name, title, email address and phone number, and we will promptly respond.

The Chair has adopted on an emergency basis, theaddition of subdivision (d) to 12 NYCRR 329-1.3, to allow reimbursement for COVID-19 testing when there is a claim for workers' compensation benefits due to workplace exposure to COVID-19. A Notice of Emergency Adoption will be published in the September 2, 2020, edition of theState Register. This emergency rulemaking is effective for 90 days upon filing August 17, 2020.

NYS WCB Response to the Novel Coronavirus, COVID-19

NYS WCB Response to the Novel Coronavirus, COVID-19

• In section five of the Guidance Document ("Other IMEs"), it states that when adjudicating a Rocket-Docket case (a controverted claim), or any other situation where an Independent Medical Examination (IME) has been directed by the Board, that an affidavit is required in order to support a request for an extension of time to obtain an IME. Given the difficulty in obtaining notarization during the emergency, will the Board allow the carrier to provide the reasons for the extension in a format other than a notarized affidavit?
  Yes. The Chair has suspended the affidavit requirement in 12 NYCRR 300.38(g)(8) for Rocket Docket cases, as well as the requirement described for other Board-directed IMEs, and allows for either an affirmation (if by an attorney) or a letter request that contains all of the required elements set forth in section 5 of the Guidance Document, except the notarized and/or original signature. This will remain in effect during the existing emergency.

NYS WCB Response to the Novel Coronavirus, COVID-19

Emergency Relief from Original Signature Requirements on Listed Documents

• In the list of forms which require the signatures of claimants, attorneys, payers and administrators, during the current state of emergency,Waiver Agreement – Section 32 WCL (Form C-32)is included. Is the Board also including theSettlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement (Form-C-32-I)?
  Yes. The relief from the original signature requirement also encompasses the Indemnity Only Section 32 Waiver Agreement form. All requirements set forth in the Guidance Document must be met to verify the non-original signature and claimant's assent.

Guidance on Changes to the NYS Workers’ Compensation System April 2020

On March 16, the Board issued guidance to stakeholders to help them handle the effects of COVID-19 on the New York State workers’ compensation system. This provided comprehensive details on how the Board is addressing all areas that could be affected by the outbreak. Changes include:

1. All hearings will be by remote attendance until further notice.

2. The 90-day requirement for medical evidence of ongoing disability has been relaxed.

3. Claimants should notify their attorney, the doctor and the Board if they can’t attend Independent Medical Examinations (IMEs). 4. A conflicting opinion may be based on a record review, instead of an in-person exam, when an Attending Doctor’s Request for Authorization and Carrier’s Response (Form C-4 AUTH) is filed and an IME is not able to be scheduled in time to meet the 30-day requirement.

5. Extensions may be possible for other IMEs.

6. Extensions may be possible for depositions (cross-examination of medical witnesses).

7. The Board may consider excusing untimely filings of applications involving appeals and rebuttals.

8. The Bureau of Compliance will consider applications to excuse delays and defaults in redetermination requests. NOTE: These changes do not remove the requirement of an employer to obtain and maintain the required coverage.

9. The Payor Compliance Unit will consider applications to excuse delays and defaults in complying withprovisions used in measurements of timely First Report of Injury (FROI), timely Subsequent Report of Injury (SROI) showing initial payment, timely initial payment, timely initial installment payment and timely notice of controversy.

Full details on each of the areas listed in this section can be found on the Board’s website under NYS WCB Response to the Novel Coronavirus, COVID-19

Some Original Signature Requirements Waived During COVID-19 Pandemic April 2020

The Board is offering relief from the requirement for handwritten signatures on 27 forms until further notice. We understand many attorneys and law firm staffers, as well as people who work for payers and administrators, are working from home during the outbreak and in some cases cannot submit required forms with original handwritten signatures. The forms affected, as well as new processes to follow, are listed on the Board’s website.

More guidance about requirements regarding handwritten signatures and IMEs is available on the Board’s website under WCB COVID-19 Guidance: Frequently Asked Questions.

Submitting Prior Authorization Requests to Carriers’ Designated Email Contact April 2020

In response to staffing and other changes put in place related to the COVID-19 pandemic, the Board is updating some processes to ensure timely continuity of programs within the workers’ compensation system.

Health care providers are advised to submit prior authorization requests for medical procedures to insurance carriers’ designated email contact as posted on the Board’s website, and not via fax.

Prior authorization requests for non-formulary medications should continue to be submitted through the medical portal. All insurance carriers, self-insured employers, and third-party administrators should forward their fax number to their designated email contact to ensure that these requests are received and acted upon accordingly.

The Board will only issue an Order of the Chair (OOC) for emailed prior authorization requests listed below that are not responded to in a timely manner. An OOC will not be issued for a faxed prior authorization request. These instructions pertain to the following forms: ·

Attending Doctor’s Request for Optional Prior Approval and Carrier’s/Employer’s Response (Form MG-1) ·

Attending Doctor’s Request for Approval of Variance and Carrier’s Response (Form MG-2)

Attending Doctor’s Request for Authorization and Carrier’s Response (Form C-4 AUTH)

Medical Treatment Guidelines Administrators: Please verify (and if necessary, update) your designated email contact

Changes to Submission of Medical Bills and Attached Reports April 2020

The Board has issued new guidance to payers that are submitting medical bills and attached reports to help accommodate those with staff working from home during the pandemic.

If the medical bill is already in the case folder, the submitter should complete the form and note the Document ID for the medical bill. A copy should not be attached.

If the medical bill is not already in the case folder, and the submitter cannot attach it to the Notice of Treatment Issue(s)/Disputed Bill Issue(s) (Form C-8.1B), then the medical bill can be submitted separately, if the medical bill is submitted on the same day as the Form C-8.1B. A notation on the form of a same-day medical bill submission is also acceptable proof.

A photo or image of the medical bill is acceptable in lieu of a scanned copy; however, photos taken on mobile devices may produce files that are too large. Our scanning vendor recommends downloading the free Genius Scan app to scan medical bills instead. Genius Scan is available

on Apple iOS and Android devices.

Forms should be submitted by email to wcbclaimsfiling@wcb.ny.gov. Detailed guidance can be found on the Board’s website.

New Nature/Cause of Injury Codes in Response to COVID-19 April 2020

New nature and cause of injury codes are now available in response to the COVID-19 pandemic. The Workers’ Compensation Insurance Organizations (WCIO) has updated the Injury Description Tables that are used by the International Association of Industrial Accident Boards and Commissions (IAIABC) to reflect this specific coding. The new codes were approved by the WCIO and are now available on the WCIO website

Letter From Chair Rodriguez to Carriers and Payers of Workers' Comp

Employees may develop COVID-19 during their employment, resulting in serious illness or even death. For those suffering from illness, there will be lost time from work and potentially significant medical expenses

As carriers and payers of workers' compensation, you provide crucial benefits to both employees and employers. The employee receives the lost time and medical benefits stemming from a compensable claim, and the employer has the peace of mind of knowing its insurance coverage will ensure its employees are covered.

As the neutral administrator of the workers' compensation system, I urge you to be mindful and helpful to your policyholder's employees during this challenging time by

Being pro-active in distributing information about how to file a claim. Employees who develop COVID-19 during the course of their employment should be encouraged to file claims.

Informing your policyholder/employers that it is illegal under WCL § 120 to take any retribution or discriminatory act against an employee who asks for a claim form or indicates that he or she may file a claim.

Ecouraging your policyholders to help their employees file claims.

Reviewing claims carefully and accepting liability whenever legally required.

Conducting an investigation into the claim as quickly as possible, even if a medical report has not been received yet.

If you still aren't sure whether a claim is compensable, even with a medical report, consider using WCL § 21-a (payment without initially accepting liability), whenever possible, rather than disputing the claim.

If you do controvert a claim, please know that the Board will follow its Rocket-Docket procedures and resolve the claim quickly. No New Yorker should have to face a lengthy bureaucratic process in pursuit of workers' compensation benefits.

Many insurance carriers, self-insured employers and third-party administrators are having their staff work from home during the Novel Coronavirus (COVID-19) health emergency. To accommodate this situation, the Board has changed its guidance on submitting medical bills and attached reports.

For payers submitting these documents to the Board, we ask that you please follow these guidelines:

If the medical bill is already in the case folder, the submitter should complete the form and note the Document ID for the medical bill. A copy should not be attached.

If the medical bill is not already in the case folder, and the submitter cannot attach it to theNotice of Treatment Issue(s)/Disputed Bill Issue(s) (Form C-8.1B),then the medical bill can be submitted separately, if the medical bill is submitted on the same day as the Form C-8.1B. A notation on the form of a same day medical bill submission is also acceptable proof.

A photo or image of the medical bill is an acceptable submission in lieu of a scanned copy; however, our scanning vendor has advised us that photos taken on a mobile device produce large files that are not amenable to scanning. The vendor recommends downloading the Genius Scan app onto a mobile device for scanning medical bills. Genius Scan is a free download and produces image files that are smaller in size, and can be downloaded for anApple iOS or Android device.

Forms should be submitted by email to wcbclaimsfiling@wcb.ny.gov.

The medical bill should not also submitted by paper mail (this would create a duplicate in the case folder).

Buffalo and Jamestown hearings are now running as scheduled

NYS WCB Response to the Novel Coronavirus, COVID-19

In section five of the Guidance Document ("Other IMEs"), it states that when adjudicating a Rocket-Docket case (a controverted claim), or any other situation where an Independent Medical Examination (IME) has been directed by the Board, that an affidavit is required in order to support a request for an extension of time to obtain an IME. Given the difficulty in obtaining notarization during the emergency, will the Board allow the carrier to provide the reasons for the extension in a format other than a notarized affidavit?

• Yes. The Chair has suspended the affidavit requirement in 12 NYCRR 300.38(g)(8) for Rocket Docket cases, as well as the requirement described for other Board-directed IMEs, and allows for either an affirmation (if by an attorney) or a letter request that contains all of the required elements set forth in section 5 of the Guidance Document, except the notarized and/or original signature. This will remain in effect during the existing emergency.

In the list of forms which require the signatures of claimants, attorneys, payers and administrators, during the current state of emergency,Waiver Agreement – Section 32 WCL (Form C-32)is included. Is the Board also including theSettlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement (Form-C-32-I)?

• Yes. The relief from the original signature requirement also encompasses the Indemnity Only Section 32 Waiver Agreement form. All requirements set forth in the Guidance Document must be met to verify the non-original signature and claimant's assent.

NYS WCB Response to the Novel Coronavirus, COVID-19

• In section five of the Guidance Document ("Other IMEs"), it states that when adjudicating a Rocket-Docket case (a controverted claim), or any other situation where an Independent Medical Examination (IME) has been directed by the Board, that an affidavit is required in order to support a request for an extension of time to obtain an IME. Given the difficulty in obtaining notarization during the emergency, will the Board allow the carrier to provide the reasons for the extension in a format other than a notarized affidavit?
  Yes. The Chair has suspended the affidavit requirement in 12 NYCRR 300.38(g)(8) for Rocket Docket cases, as well as the requirement described for other Board-directed IMEs, and allows for either an affirmation (if by an attorney) or a letter request that contains all of the required elements set forth in section 5 of the Guidance Document, except the notarized and/or original signature. This will remain in effect during the existing emergency.

Emergency Relief from Original Signature Requirements on Listed Documents

In the list of forms which require the signatures of claimants, attorneys, payers and administrators, during the current state of emergency,Waiver Agreement – Section 32 WCL (Form C-32)is included. Is the Board also including theSettlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement (Form-C-32-I)?

• Yes. The relief from the original signature requirement also encompasses the Indemnity Only Section 32 Waiver Agreement form. All requirements set forth in the Guidance Document must be met to verify the non-original signature and claimant's assent.

eClaims Change LogThe Edit Matrix-Population Restriction Table has been updated. The updates are summarized on the eClaims change log under Items #398-400 announcing the following changes:

• Per IAIABC notification of 3/20/2020, WCIO has added a new Cause Code of 83 for Pandemic and a new Nature Code of 83 for COVID-19. The new Injury Description Tables may be found on the WCIO website atwww.wcio.org. New York has added these codes to their Claims EDI tables for FROI reporting effective 3/25/2020, for DN0035 (Nature of Injury) Code and DN0037 (Cause of Injury) Code. Note: It is expected that FROI-02s are filed if FROIs have already been filed with incorrect Cause or Nature codes since the NY Element Requirement Table lists both of the data elements severity ranking "Y".
• Effective 10/1/2020, new Population Restriction for DN0031 (Date of Injury) will be applied with Error 064 Invalid Data Relationship - Population Restriction E) Date of Injury (DN0031) year must be on or after 2019 if Nature of Injury (DN0035) is COVID-19 (83) or Cause of Injury (DN0037) is Pandemic.
• Effective 10/1/2020, new Population Restriction for DN0290 (Type of Loss) will be applied with Error 064 Invalid Data Relationship - Population Restriction - Type of Loss (DN0290) must be Occupational Disease (02) if Nature of Injury (DN0035) is COVID-19 (83) or Cause of Injury (DN0037) is Pandemic (83).

The Workers’ Compensation Insurance Organizations (WCIO) has updated the Injury Description Tables that are used by the International Association of Industrial Accident Boards and Commissions (IAIABC) to reflect specific coding in response to COVID-19. The new Nature/Cause of Injury Codes were approved by the WCIO and are now available on theWCIO website.

A new Cause of Injury Code (DN0037) – 83 for “Pandemic” and a new Nature of Injury Code (DN0035) – 83 for “COVID-19” are anticipated to be used for the reporting of any cases with a Type of Loss (DN0290) = 02 (OD) with a Date of Injury (DN0031) of December 2019 or later.

When Filing a First Report of Injury (FROI)

If a FROI was filed for COVID-19 before the new codes became available in the system, a FROI-02 should be filed using the new codes. This is on theNY Element Requirement Tablerankings as a required filing.

Population Restrictions Coming this October

Effective October 1, 2020, we will be implementing two Population Restrictions:

• DN0031 (Date of Injury)will be applied with “Error 064 Invalid Data Relationship – Population RestrictionDate of Injury (DN0031).” The year must be on or after 2019 ifthe Nature of Injury (DN0035) is COVID-19 (83) or the Cause of Injury (DN0037) is Pandemic.

• DN0290 (Type of Loss)will be applied with “Error 064 Invalid Data Relationship – Population Restriction – Type of Loss (DN0290).” The Type of Loss must be Occupational Disease (02) if the Nature of Injury (DN0035) is COVID-19 (83) or the Cause of Injury (DN0037) is Pandemic (83).

WCB Response to COVID-19 Pandemic: Emergency Relief from Original Signature Requirements on Listed Documents

On March 16, 2020, the Board published aCOVID-19 Guidance Documentdescribing the anticipated impacts on the workers’ compensation system due to the current public health crisis and steps taken by the Board in response. In addition, the Board has commencedmandatory remote-only Virtual Hearing attendanceand continues to work to ensure, to the greatest extent possible, ongoing operations and benefit flow to injured workers.

Since issuing the initial COVID-19 Guidance Document on March 16, 2020, the Board has received many questions from attorneys about the need for signatures on certain documents. Many attorneys, other law firm staff, and employees of payers and administrators are working from home during this crisis and are unable in some instances to submit required forms with original handwritten signatures.

To that end, the Board is hereby suspendinguntil further noticethe requirement for original handwritten signatures on the following forms (all language versions), which require the signatures of claimants, attorneys, payers and administrators, during the current state of emergency:

• Employee Claim (Form C-3) – Paper
• Waiver Agreement – Section 32 WCL (Form C-32)
• Section 32 Settle Agreement: Claimant Release (Form C-32.1)
• Stipulation (Form C-300.5)
• Agreed Upon Findings And Awards for Proposed Conciliation Decision (Form C-312.5)
• Extreme Hardship Redetermination Request (Form C-35)
• Claim for Compensation in Death Case (Form C-62)
• Notice of Retainer and Substitution (Form OC-400)
• Application for a Fee by Claimant’s Attorney or Licensed Representative (Form OC-400.1)
• Attorney/Representative’s Certification of Form C-3 or Notice of Controversy (Form OC-400.5)
• Attorney/Licensed Representative Request to Withdraw from Representation (Form OC-400.17)
• Notice of Retainer and Appearance on Behalf of Employer (Form OC-406)
• Pre-Hearing Conference Statement (Form PH-16.2)
• Application for Board Review (Form RB-89)
• Rebuttal of Application for Board Review (Form RB-89.1)
• Application for Reconsideration/Full Board Review (Form RB-89.2)
• Rebuttal of Application for Reconsideration/Full Board Review (Form RB-89.3)
• Request for Further Action by Injured Worker (Form RFA-1W) –Paper
• Request for Further Action by Legal Counsel (Form RFA-1LC) – Paper
• Request for Further Action by Carrier/Employer (Form RFA-2) – Paper
• Notice to Liable Political Subdivision of Volunteer Ambulance Worker’s Injury or Death (Form VAW-1)
• Volunteer Ambulance Worker’s Claim for Benefits (Form VAW-3)
• Claim for Volunteer Ambulance Worker’s Benefits in a Death Case (Form VAW-62)
• Loss of Wage Earning Capacity Vocational Data (Form VDF-1) – Paper
• Notice to Liable Political Subdivision of Volunteer Firefighter’s Injury or Death (Form VF-1)
• Volunteer Firefighter’s Claim for Benefits (Form VF-3)
• Claim for Volunteer Firefighter Benefits in a Death Case (Form VF-62)

Where a form is identified as ‘Paper’ (e.g., Request for Further Action by Injured Worker [Form RFA-1W] – Paper), it is a paper version of a form that can also be completed electronically and submitted online. All forms are listed at:http://www.wcb.ny.gov/content/main/forms/AllForms.jsp

Claimants

As a result of the COVID-19 crisis, it is anticipated that claimants will be unable to meet in person with their legal representatives in order to sign documents drafted by counsel, which require the claimant’s signature. Therefore, during this State of Emergency, forms may be executed by a represented claimant as follows:

• If any of the forms listed above require the claimant’s signature, the claimant may indicate his or her approval of the document, which will be attested to by his or her attorney. The claimant may do so in several ways: (1) by signing the form electronically in accordance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulations (9 NYCRR Part 540); or (2) by indicating his or her approval of the document in another manner (for example, an email) to his or her legal representative; and
• The attorney or licensed representative who represents the claimant shall submit the form to the Board with an additional attestation by the attorney, on the letterhead of his or her firm, which states either:

I, ___________________________, hereby attest that I am an [attorney/licensed representative] with the firm of ____________________________, with its principal place of business located at the address indicated on the letterhead above and identified by the Workers' Compensation Board in its system using the following identifier (W, R or other number): ________________, who represents the claimant, _______________ in WCB # __________. The claimant signed the attached document, [FORM ID], using an electronic signature process that meets the requirements set forth in the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulations (9 NYCRR Part 540). I fully explained to the claimant that the [FORM ID] would be submitted to the Board on his/her behalf.

-OR -

I, ___________________________, hereby attest that I am an [attorney/licensed representative] with the firm of ____________________________, with its principal place of business located at the address indicated on the letterhead above and identified by the Workers' Compensation Board in its system using the following identifier (W, R or other number): ________________, who represents the claimant, _______________ in WCB # __________. I fully discussed the contents of the attached document, [FORM ID], with the claimant and hereby attest that claimant understood the contents of the [FORM ID] and conveyed his or her approval of the contents of the document to me. I explained to the claimant that the [FORM ID] would be submitted to the Board on his/her behalf.

• The attorney shall certify this attestation, providing his or her given name and the firm name and R number. This certification can be signed electronically as provided below.

Attorneys/ Licensed Representatives

During this State of Emergency, forms may be executed by attorneys and licensed representatives appearing in claims before the Workers’ Compensation Board as follows:

• If any of the forms listed above require the signature of an attorney or licensed representative, the attorney or licensed representative may sign the form electronically in accordance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulations (9 NYCRR Part 540); and
• The attorney or licensed representative shall submit the form to the Board with an additional attestation by the attorney or licensed representative, on the letterhead of his or her firm, which states as follows:

I, ___________________________, hereby attest that I am an [attorney/licensed represented] with the firm of ____________________________, with its principal place of business located at the address indicated on the letterhead above and identified by the Workers' Compensation Board in its system using the following identifier (R number): ________________, who represents _______________ WCB # __________ in this matter. I have signed the attached document, [FORM ID], using an electronic signature process that meets the requirements set forth in the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulations (9 NYCRR Part 540).

• The attorney shall certify this attestation, providing his or her given name and the firm name, and R or W number. This certification can be signed electronically in accordance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulations (9 NYCRR Part 540).
• In the form’s signature line, the attorney should type his or her name, and/or the claimant’s name, as indicated.