Pre-Hearing Conference Statement
1. Summary:
*
Provide a brief summary of the claim. Give the theory of the case with statutory and, if appropriate, case citations.
2. Carrier/Self-Insured Employer Defenses:
a. [carrier/self-insurer only] List all the defenses that carrier is raising along with an offer of proof for each defense raised. If the carrier is raising an allegation that claimant has not presented prima facie medical evidence, please indicate and provide a basis for such challenge.
b. Did the injury occur while the claimant was working in the construction industry as defined in the New York State Construction Industry Fair Play Act (Labor Law § 861-B)?
Yes
No
Did the injury occur while the claimant was driving in the commercial goods transportation industry as defined in the New York State Commercial Goods Transportation Industry Fair Play Act (Labor Law § 862-B)?
Yes
No
3. Additional Parties:
*
Provide the names of additional parties, if any, necessary to the adjudication of the claim, and explain why they are necessary. If none, so state.
4. Lay Witnesses:
*
Provide the names, addresses, and employers, if known, of all lay witnesses, including claimant, you intend to present, along with a statement as to the nature of their testimony and the estimated time needed for testimony. If none, so state. Please note: lay witness testimony will be taken at the first expedited hearing following the pre-hearing conference.
5. Medical Witnesses:
*
Provide the names of any medical witnesses you intend to cross-examine, if known, whether you wish the cross-examination by deposition or at a hearing, and the estimated time needed for the cross-examination. If none, so state. Please note: depositions shall be conducted and transcripts filed with the Board no more than 55 days from the pre-hearing conference.
6. Attachments:
List and attach all reports, forms, or documents necessary to the resolution of the claim that have not already been submitted to the Board's electronic case file.
7. Discovery:
If no, detail what further discovery is necessary and why it will not be completed prior to the pre-hearing conference.
8. IME:
If yes, when?
Please note: IME reports on the threshold issue of causal relationship shall be served and filed three days prior to the
initial expedited hearing or the first hearing in accordance with 300.33(f)(12).
9. Release of Medical Records:
Does the carrier request that the claimant provide a broader release for medical records than that provided on the Limited Release of Health Information (Form C-3.3)?
Yes
No
If yes, the carrier or its legal representative must file with the Board along with this conference statement an affidavit or
affirmation setting forth the relevance of the medical records sought.
10. Average Weekly Wage:
*
What is the proposed average weekly wage if the claim is found compensable?
On what evidence is this based? (If not already filed, the carrier must also submit a C-240 form)
11. Work Status:
*
What is the claimant's current work status? (If not already filed, the carrier must also submit a C-11 form, if appropriate.)
12. Settlement:
* Has a good faith effort been made to settle or otherwise resolve the claim for benefits?
Yes
No
The information contained in this form will facilitate the just, speedy and efficient disposition of the claimant's right to
workers' compensation benefits, including settlement as required by Section 300.38(f)(1) of 12 NYCRR.