Notice Of Appeal From Decision Of Workers Compensation Board {AD3 NoA WCB}

NOTICE OF APPEAL TO APPELLATE DIVISION, THIRD DEPARTMENT FROM DECISION OF WORKERS' COMPENSATION BOARD STATE OF NEW YORK SUPREME COURT APPELLATE DIVISION THIRD DEPARTMENT In the Matter of the Claim for Compensation Under the Workers' Compensation Law made by Claimant, v NOTICE OF APPEAL WCB No. and Respondents. WORKERS' COMPENSATION BOARD, Respondent. , Employer, , Insurance Carrier, PLEASE TAKE NOTICE that the above-named Claimant (or Employer, Insurance Carrier) in this matter, hereby appeal(s) to the Appellate Division of the Supreme Court, Third Judicial Department, from the decision of the Workers' Compensation Board, filed the Dated: day of , 20 , and from each and every part thereof. (Signature) (Print Name) (Address) (Telephone) TO: (name[s] and address[es] of attorney[s] for other party/parties) Note: The notice of appeal must also be filed in the office of the Secretary of the Workers' Compensation Board. Revised: February 19, 2014 American LegalNet, Inc. www.FormsWorkFlow.com