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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:
Claimant Information
   
Employer Information
Insurer Information
Attorney or Licensed Representative Information
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:

pursuant to 12 NYCRR 300.23(b).
(medical or payroll documentation supporting suspension required)
pursuant to 12 NYCRR 300.23(b).
(medical or payroll documentation supporting reduction required)
(payroll documentation supporting modification required)
as claimant has voluntarily removed him/herself from or is no longer attached to the labor market.
(documentation supporting suspension required)
because of disqualification pursuant to WCL §114-a.
(list of documents or evidence to be produced required)

Medical Issues:

(medical documentation indicating permanency required)
(medical documentation indicating permanency required)
12 NYCRR 300.22 the insurer contends:
  
(statement as to the insurer's position on the payment of further benefits required)
(medical documentation indicating weaning goals and recommended weaning program/resource is required)
(insurer must state what treatment is not related, and why)

Other:

(Form C-300.5 or written stipulation required)
(Form C-312.5 or proposed findings required)
(documents indicating discontinuance, settlement, or closing statement required)
(Form C-251.6R and all related forms and emails to and from SFG required per SN046-1063R. New evidence may not be submitted)
(documents required)
(explain fully in space provided below)
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:

Certified By

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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