TESTIMONY BY INVITATION ONLY

PUBLIC HEARING REPLY FORM

Persons wishing to present testimony at the public hearing on The Workers Compensation Security Fund are requested to complete this reply form as soon as possible and mail it to:

Louann Ciccone
Principal Legislative Analyst
Assembly Committee on Insurance
Room 520 - Capitol
Albany, New York 12248
Email: cicconl@assembly.state.ny.us
Phone: (518) 455-4928
Fax: (518) 455-5182


box I plan to make a public statement at the hearing on The Workers Compensation Security Fund, on May 3, 2005. My statement will be limited to 15 of minutes, and I will answer any questions which may arise. I will provide 10 copies of my prepared statement.

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I will address my remarks to the following subjects:



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I will require assistance and/or handicapped accessibility information. Please specify the type of assistance required:




NAME:

TITLE:

ORGANIZATION:

ADDRESS:

E-MAIL:

TELEPHONE:

FAX TELEPHONE:
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