NY Workers' Compensation Commission

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  Application for a Fee by Claimant’s Attorney or Representative

  NYWC_OC-400.1 $89.00
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  Application for Acceptance of Insurance Form

  NYWCDB850 $69.00
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  Carrier’s Report on Rehabilitation

  R $69.00
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  Carrier’s Request for Reimbursement of Compensation Payments Under Section 14(6) Concurrent

  NYWC_C-251.2 $69.00
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  Carrier’s Request for Reimbursement of Compensation Under Section 15-8

  NYWC_C-251 $89.00
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  Carrier’s Request for Reimbursement of Medical Expenses Under Section 15-8

  NYWC_C-251.1 $69.00
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  Claimant’s Authorization to Disclose Workers’ Compensation Records

  NYWC_OC-110A $69.00
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  Cover Sheet & Rebuttal of Application for Board Review

  RB-89.1 $89.00
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  Discharge or Discrimination Complaint

  NYWCDC120 $69.00
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  Employer’s Report of Accident

  NYWC_C-2 $89.00
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  Employer’s Report of Injured Employee’s Change in Status or Return to Work

  NYWC_C-11 $89.00
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  Employer’s Statement of Wage Earnings Preceding Date of Accident

  NYWC_C-240 $89.00
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  Form Letter Requesting Medical Information

  NYWCDB3103 $39.00
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  Notice of Claim for Reimbursement Out of Special Disability Fund Under Section 15-8

  NYWC_C-250 $69.00
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  Notice of Retainer and Substitution

  NYWC_OC-400 $89.00
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  Notice of Total or Partial Rejection of Claim for Disability Benefits

  NYWCDB451 $89.00