Request For Further Action By Insurer/Employer

ERFA-2

State of New York - Workers' Compensation Board

THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.

ATTENTION: Please read these Instructions before completing and submitting the ERFA-2.

If you have used the previous version of this form, please be aware that some functions such as Adding Attachments have changed. Please read How to Submit for additional information.

REFERENCE DOCUMENTS ALREADY IN THE BOARD'S ELECTRONIC FILE OR ATTACH ALL APPLICABLE EVIDENCE FOR CONSIDERATION BY THE BOARD.

Required items are indicated by an *.

Case Information

* This form is submitted by:

Insurer Self-Insurer Special Funds Group

* WCB Case Number:

Claim Admin Claim Number:

* Insurer Code Number:

* Date of Injury:

Claimant Information

* Last Name: * First Name: MI:

* Address: Check if new address

Line 2:

* City: State: Zip Code: Country:

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Employer Information

* Name:

* Address:

Line 2:

* City: State: Zip Code: Country:

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Insurer Information

* Name:

* Address:

Line 2:

* City: State: Zip Code: Country:

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Attorney or Licensed Representative Information

Name:

Address:

Line 2:

City: State: Zip Code: Country:

Attorney/Representative ID Number:

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Compensation/Medical Issues/Other

INSTRUCTIONS

The Insurer/employer seeks Board action regarding the claim identified above for the following reasons (check all that apply). Please note that the required documentation identified below must be attached to the form and submitted to the Board or must be referenced in the space provided below** (by date, name or title of document, and form ID) if it is already in the Board's electronic file. A copy of this form and the attachments must be sent to the claimant and claimant's representative if one has been retained. A copy of this form and the attachments must also be sent to the health care provider if item a or b is checked.

Compensation:

a. Continuing payments directed by the Board should be suspended as of pursuant to 12 NYCRR 300.23(b).

(medical or payroll documentation supporting suspension required)

b. Continuing payments directed by the Board should be reduced to /wk as of pursuant to 12 NYCRR 300.23(b).

(medical or payroll documentation supporting reduction required)

c. Payments should be modified as claimant is working at full or reduced earnings as of

(payroll documentation supporting modification required)

d. Payments should be suspended as of as claimant has voluntarily removed him/herself from or is no longer attached to the labor market.

(documentation supporting suspension required)

e. Payments should be suspended as of because of disqualification pursuant to WCL §114-a.

(list of documents or evidence to be produced required)

Medical Issues:

f. Claimant's disability is now amenable to a facial award or schedule loss of use award.

(medical documentation indicating permanency required)

g. Claimant's disability is now amenable to a non-schedule award.

(medical documentation indicating permanency required)

h. Claimant has made an application to reopen a previously established claim seeking additional benefits and pursuant to 12 NYCRR 300.22 the insurer contends:

(statement as to the insurer's position on the payment of further benefits required)

i. Opioid Weaning under Non-Acute Pain Guidelines.

(medical documentation indicating weaning goals and recommended weaning program/resource is required)

j. Request denial of future treatment that insurer contends is not related to an established site or condition.

(insurer must state what treatment is not related, and why)

Other:

k. Parties have entered into a stipulation.

(Form C-300.5 or written stipulation required)

l. Parties have reached an agreement and seek a Proposed Conciliation Decision.

(Form C-312.5 or proposed findings required)

m. Claimant has discontinued or settled a lawsuit pertaining to the accident/injury of this claim.

(documents indicating discontinuance, settlement, or closing statement required)

n. Insurer seeks desk review of Special Funds Group reimbursement decision Form C-251.6R.

(Form C-251.6R and all related forms and emails to and from SFG required per SN046-1063R. New evidence may not be submitted)

o. Insurer has new or requested documentation regarding:

(documents required)

p. Other

(explain fully in space provided below)

(explain fully in space provided below.)

** Document reference information (date, name / title, form ID):

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Sign

I certify that this request for Board action is based upon reasonable grounds, and that this form with attachment(s) has been provided to the opposing party(ies).

I also certify that:

I have discussed the issue(s) above with the opposing party(ies) or its representative(s)
I attempted to contact the opposing party(ies) to discuss the issue(s).

Certified By

* First Name: * Last Name: MI:

WCB ID Number:

Telephone Number:

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Select File(s) to Attach

If you have used the previous version of this form, please be aware that some functions such as Adding Attachments have changed. Please read How to Submit for additional information.

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State of New York - Workers' Compensation Board

Compensation:

Medical Issues:

Other:

Certified By

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