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STATE OF NEW YORK - WORKERS' COMPENSATION BOARD …

SEE IMPORTANT INFORMATION ON REVERSERFA-1LC (4-17)INSTRUCTIONS: The claimant seeks BOARD action regarding the claim identified above for the following reasons (check all that apply). Please note that the required documentation identified below must be attached to the form and submitted to the BOARD or must be referenced in the space provided below** (by date, name or title of document, and form ID) if it is already in the BOARD 's electronic file. This form must be mailed, faxed or emailed to the Workers' COMPENSATION BOARD . (See mailing and email filing address on reverse side). STATE OF NEW YORK - WORKERS' COMPENSATION BOARD request FOR further action BY LEGAL COUNSEL 8.(documentation of medical disability and current earnings required)d. Payments should be adjusted as claimant is working at reduced earnings as ofCERTIFIED BY (Please Print Name)DATE PREPARED (MM/DD/YY)ATTY/REP ID CODETELEPHONE NUMBERRC ompensation:Other:Medical Issues:2.

REQUEST FOR FURTHER ACTION BY LEGAL COUNSEL. 8. (documentation of medical disability and current earnings required) d. Payments should be adjusted as claimant is working at reduced earnings as of. CERTIFIED BY (Please Print Name) ATTY/REP ID NO. DATE PREPARED (MM/DD/YY) AREA CODE. TELEPHONE NUMBER R. Compensation: Other: …

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