Get State Of New York - Workers ' Compensation Board Renewal Application For License To Appear On

Completing the State of New York - Workers' Compensation Board Renewal Application for License to Appear On is a crucial process for those looking to renew their representation licenses. This guide provides step-by-step instructions to help you navigate the application process effectively and confidently.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate which section of the Workers' Compensation Law you're applying under by checking either 'Section 50 3-b' or 'Section 50 3-d'.
3. Fill in the applicant's name or organization's name in the designated space along with the type of organization (individual, partnership, corporation, or other).
4. If any other names have been used since your last application, check 'Yes' and provide those names. Otherwise, check 'No'.
5. Enter your business address and contact information, including business telephone number and fax number.
6. Indicate whether your company has other offices in New York State. If yes, attach a list containing necessary details.
7. Provide the names and home addresses of individuals, partners, or officers and directors of the corporation. Attach a list if there are more than three.
8. List all principal stockholders who own at least 20% of the corporation's stock and indicate the percentage owned by each. Remember that each must complete Form OC-403.3.
9. Identify the individuals who will represent you before the Board, agreeing to notify the Board of any changes and surrender invalid authorization cards. Attach completed Form OC-403.2 for each listed employee.
10. List all self-insured entities and carriers represented within the past year.
11. Complete the personal history section by providing necessary information including employment history and education, responding to questions about citizenship status, disbarments, criminal convictions, pending charges, and arrangements with healthcare providers.
12. Authorize the Workers' Compensation Board to obtain verification of the information provided. Ensure to sign the application as required.
13. Finalize the application by having a qualifying officer of a corporate applicant complete their section including notarization if necessary.
14. After ensuring that all sections are completed and accurate, save your changes, and either download, print, or share the form as needed.

Complete your application online today to ensure your license remains active.