13. Hearing Dates, Transcripts, Documents, Exhibits, and Other Evidence. Indicate the hearing date(s) on which the
issue(s) was raised before the WCLJ, as well as any other relevant hearing dates. Identify by date and/or documents ID
number(s) the transcripts, documents, reports, exhibits, and other evidence in the Board's file that are relevant to the issues and
grounds being raised for review. If minutes are not transcribed, so indicate. Do not include with or attach to an Application for
Board Review any documents that are present in the Board's file at the time the Application is filed. The Board may reject an
Application for Board Review by an appellant or an appellant's legal representative who attaches documents already in the
Board's file at the time of the Application, in accordance with 12 NYCRR 300.13(b)(1)(ii). Do not attach or submit transcripts of
audio recorded hearings, as the Board will not consider them.
14. New and Additional Evidence. If an appellant seeks to introduce new or additional evidence with the Application for Board
Review that was not presented before the WCLJ, the appellant must, 1) state on the Application whether such evidence is
attached to the Application, or is in the Board's file, specifying the applicable document ID number, and 2) submit a sworn
affidavit or affirmation setting forth the evidence, and explaining why such evidence could not have been presented before the
WCLJ. The Board may or may not exercise its discretion to accept such evidence. If the sworn affidavit or affirmation is not
submitted with the Application, such new or additional evidence will not be considered by the Board Panel [see 12 NYCRR
300.13(b)(1)(iii)].
15. Objection or Exception. Specify the objection or exception that was interposed to the ruling, and the date when the
objection or exception was interposed as required by 12 NYCRR 300.13(b)(2)(ii). If the objection or exception was interposed at
a hearing, the date of the hearing at which the objection or exception was interposed must be stated. If the objection or exception
was interposed at a proceeding occurring off-calendar, the date of the off-calendar proceeding must be stated
[12 NYCRR 300.13(b)(4)(v)(a), (b), and (c)].
16. Indemnity Payments. When the Application is filed by the carrier or self-insured employer, indicate whether indemnity
benefits are being paid while the application is pending. If no, indicate the date on which payments were suspended pursuant to
WCL § 23. If yes, indicate the rate at which continuing indemnity benefits are being paid. If continuing indemnity benefits are
being paid at a rate that is less than the awarded rate, specify the date on which payments were reduced. If payments are
stayed, state the issue on appeal that forms the legal basis for staying payments. This item/section does not apply to claims for
discrimination.
17. Attorney's fees. When the Application is filed by the claimant's legal representative, indicate whether an increase in
attorney's fees is being requested. If yes, Form OC-400.1, Application for a Fee by Claimant's Attorney or Representative, must
be attached and served on the parties [see12 NYCRR 300.13(b)(2)(v) and 300.17)]. Failure to request an additional fee in the
Application for Board Review, and by filing a Form OC-400.1 with the Application, shall result in the waiver of any additional fee.
18. Certification. The preparer must sign and date the form (also providing their name, title, telephone number and address)
certifying to the Application's good faith basis in law and fact, that it had been instituted with reasonable grounds, and had been
served upon the necessary parties of interest in the proof of service section.
19. Proof of Service. The Application must be served on all necessary parties of interest in accordance with 12 NYCRR
300.13(b)(2)(iv). Failure to properly serve a necessary party shall be deemed defective service and the Application may be
rejected by the Board. When the Application for Board Review is filed by the carrier, self-insured employer, or other payor or
potential payor, service shall be upon the claimant, and claimant's legal representative, and other necessary parties of interest.
Service is deemed timely if completed by the appellant within thirty (30) days of the filing of the decision by the Board. Either the
Affirmation or Affidavit must be completed and must include the method by which, and the date, the Application was filed with the
Board. The appellant shall only use one method to file the Application with the Board. If the appellant files duplicate
Applications, such duplicate filings may be deemed to be raising or continuing an issue without reasonable grounds, and may
subject the appellant to assessments under WCL § 114-a(3). The Affirmation or Affidavit completed must specify the papers
served, the names of the parties of interest served, the date and method of service for each party of interest, and that service
was completed within 30 days from the filing of the decision that is the subject of the Application. It is not acceptable to complete
the portion of the affidavit or affirmation where it lists those served and the method with "See attached." If a party is served by
fax, email or other electronic means, the Affirmation or Affidavit must include a certification that the party so served provided
explicit permission to receive service by such means [see 12 NYCRR 300.13(b)(2)(iv)(C)]. The Application does not have to be
served on each party in the same manner. The Affirmation must be dated and signed under penalties of perjury. Only an
attorney may complete the Affirmation. The Affidavit must be sworn to (signed) before a notary public.
RB-89 (11-18) Instructions