Get Ny Rb-89.1 2021-2026

The NY RB-89.1 form is essential for filing a rebuttal to an application for board review. This guide will provide you with comprehensive instructions on how to fill out the form online effectively, ensuring that you meet all necessary requirements.

Follow the steps to successfully complete the NY RB-89.1 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the WCB Case Number(s) of the claim(s) being appealed. This is important for identifying your specific case.
3. Input the Carrier Case Number(s) associated with the claim. Note that this section does not apply to discrimination claims.
4. Provide the Carrier Code of the insurer for the claim being appealed. This part also does not apply to discrimination claims.
5. Fill in the Carrier's Name to specify which insurer is associated with the appeal.
6. State the Date of Injury/Leave. This should reflect the original date when the injury occurred or when paid family leave began.
7. Complete the Claimant's Name by providing the full name of the employee involved.
8. Input the Claimant's Address, including street address, city, state, and ZIP code.
9. Indicate which party is filing this rebuttal to clarify the origin of the appeal.
10. Specify the Type of Application to which the rebuttal responds. Choose between review of a WCLJ Decision or rehearing/reopening.
11. Fill in the Date of Decision to document the specific decision that is being contested.
12. Note the Date of Service to affirm when the Application was served upon you.
13. Select the Requested Outcome based on what you contend regarding the decision.
14. Provide a concise Response to Issues and Grounds, detailing your statement in response to the contested application.
15. If not relying on the full record, identify any additional evidence in the Record section.
16. State if you are presenting New and Additional Evidence; attach a sworn affidavit if applicable.
17. If necessary, specify any Objection or Exception regarding the WCLJ decision.
18. Indicate whether you will be requesting an Increase in Attorney's Fees and attach Form OC-400.1 if applicable.
19. Complete the Certification section by signing and dating the form, then provide your name, title, telephone number, and address.
20. Lastly, ensure the Proof of Service is documented correctly and submitted, adhering to the requirements stated.
21. Once completed, you can save changes, download, print, or share the completed form.

Proceed with filling out your documents online today.