Oc 409 carriers 2026

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The document is an application form from the New York Workers' Compensation Board for individuals seeking to take the License Representative Exam. It outlines the requirements and sections of the Workers' Compensation Law under which applicants can apply, including necessary personal information, background checks, and character references. The form emphasizes the importance of full disclosure in the application process.

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Begin by selecting the appropriate application type under 'APPLICATION IS MADE UNDER' by checking one of the options provided.
In Section 1, enter your full name and indicate if you have ever been known by another name. If yes, provide that name.
Fill in your home address, including street, city, and state. If you've lived at this address for less than three years, list previous addresses as well.
Provide your home telephone number and a contact number during normal business hours in Section 2.
Enter your Social Security Number in Section 3 and select your citizenship status in Section 4.
Confirm if you are over 18 years of age in Section 5 by checking 'Yes' or 'No'.
Answer questions regarding any licenses or disciplinary actions in Sections 6 and 7, providing details where necessary.
In Section 8, disclose any criminal convictions or pending charges, giving details if applicable.
Finally, list five character references in Section 9 who have known you for at least five years along with their addresses and relationship to you.

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What is a C4 form?

If youve been injured on the job, you may be entitled to workers compensation benefits. In order to receive these benefits, youll need to fill out a C4 form. This form is used to report your injury to your employer and to the workers compensation insurance carrier.

What not to say to Workmans Comp?

What Not to Say to a Workers Comp Doctor Avoid Downplaying Your Injury: Dont minimize your pain or discomfort. Dont Speculate on Recovery Time: Do not make guesses about how quickly you will recover. Stay Away from Absolute Statements: Do not use words like always or never when describing your symptoms.

What is a C-4 form?

Email to the Boards centralized email address, wcbclaimsfiling@wcb.ny.gov; Mail to the Boards centralized mailing address, P.O. Box 5205, Binghamton, NY 13902-5205; or. Fax to the Boards centralized fax number, (877) 533-0337.

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