Form OC-406 "Notice of Retainer and Appearance on Behalf of Employer" - New York

What Is Form OC-406?

This is a legal form that was released by the New York State Workers' Compensation Board - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the New York State Workers' Compensation Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form OC-406 by clicking the link below or browse more documents and templates provided by the New York State Workers' Compensation Board.

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Download Form OC-406 "Notice of Retainer and Appearance on Behalf of Employer" - New York

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TO CHAIR
State of New York
WORKERS' COMPENSATION BOARD
NOTICE OF RETAINER AND APPEARANCE ON BEHALF OF EMPLOYER
Specific information is required to identify the case(s) you have been retained for in
reference to the claimant and employer named. Please provide this information and
circle: Case Number (includes WCB, DB, DC, and PFL), Date of Accident, Paid
Family Leave ("PFL"), Start Date or PFL Discrimination Complaint Date, to indicate
the type of information you have provided. Use one line per case.
Claimant
vs.
Case Number / Date of Accident / PFL Start Date / PFL Discrimination Complaint Date
Case Number / Date of Accident / PFL Start Date / PFL Discrimination Complaint Date
* Employer
Case Number / Date of Accident / PFL Start Date / PFL Discrimination Complaint Date
Please take notice that the employer named above hereby appears in the above matter, and that the undersigned attorney
has been retained to represent said employer in regards to the above matter. All notices, decisions and other documents in
the above case are to be sent to the undersigned attorney at the address indicated below.
Date:
Signature of Attorney
Printed Name of Attorney:
Office Address:
Office Telephone Number:
Attorney's Board-assigned ID Number, if any:
R-
An R Number is required for eCase [electronic case folder] access. Information about eCase and obtaining an R Number is
available at the Workers' Compensation Board's website, www.wcb.ny.gov, under the heading Representatives.
Please take notice that I have retained the above named attorney to represent and appear by and on behalf of the
employer in all proceedings in regards to the above matter.
Date:
Signature of Person Authorized to Sign on Behalf of Employer
Printed Name of Person Authorized to Sign of Behalf of Employer
Title of Person Authorized to Sign on Behalf of Employer
This form is for use by employers and their attorneys ONLY. An attorney retained by an employer's insurance carrier is not
permitted to use this form. Both the attorney and the employer must sign this form.
* In a No-Insurance Case the "Alleged Employer."
OC-406 (1-18)
OC-406 1-18
TO CHAIR
State of New York
WORKERS' COMPENSATION BOARD
NOTICE OF RETAINER AND APPEARANCE ON BEHALF OF EMPLOYER
Specific information is required to identify the case(s) you have been retained for in
reference to the claimant and employer named. Please provide this information and
circle: Case Number (includes WCB, DB, DC, and PFL), Date of Accident, Paid
Family Leave ("PFL"), Start Date or PFL Discrimination Complaint Date, to indicate
the type of information you have provided. Use one line per case.
Claimant
vs.
Case Number / Date of Accident / PFL Start Date / PFL Discrimination Complaint Date
Case Number / Date of Accident / PFL Start Date / PFL Discrimination Complaint Date
* Employer
Case Number / Date of Accident / PFL Start Date / PFL Discrimination Complaint Date
Please take notice that the employer named above hereby appears in the above matter, and that the undersigned attorney
has been retained to represent said employer in regards to the above matter. All notices, decisions and other documents in
the above case are to be sent to the undersigned attorney at the address indicated below.
Date:
Signature of Attorney
Printed Name of Attorney:
Office Address:
Office Telephone Number:
Attorney's Board-assigned ID Number, if any:
R-
An R Number is required for eCase [electronic case folder] access. Information about eCase and obtaining an R Number is
available at the Workers' Compensation Board's website, www.wcb.ny.gov, under the heading Representatives.
Please take notice that I have retained the above named attorney to represent and appear by and on behalf of the
employer in all proceedings in regards to the above matter.
Date:
Signature of Person Authorized to Sign on Behalf of Employer
Printed Name of Person Authorized to Sign of Behalf of Employer
Title of Person Authorized to Sign on Behalf of Employer
This form is for use by employers and their attorneys ONLY. An attorney retained by an employer's insurance carrier is not
permitted to use this form. Both the attorney and the employer must sign this form.
* In a No-Insurance Case the "Alleged Employer."
OC-406 (1-18)
OC-406 1-18