I, , understand that I am settling all claims and prospective claims addressed in the proposed
Section 32 Waiver Agreement between myself and the insurance carrier and/or employer, and that once the Agreement is approved by the Board
and a ten day waiting period has elapsed, the claim(s) cannot be reopened by the Board, myself, the employer, the carrier, or any other party in
interest.
Please answer all questions below. You must check Yes or No for each question.
1. Do you understand that any party to the Section 32 Waiver Agreement may withdraw from the Agreement before the approval
becomes final? This means that any party wishing to withdraw must do so in writing. The written notice of withdrawal MUST be
received by the Board within 10 calendar days of the date the Agreement is deemed to have been submitted to the Board. (If No,
explain below.)
2. Do you understand that if no written notice of withdrawal from the Section 32 Waiver Agreement is received by the Board, within
10 calendar days of the date the Agreement is deemed to have been submitted to the Board, the Agreement is binding on all
parties and cannot be appealed? This means that once the approval of the Agreement becomes final the parties to the
Agreement may not object to any of the terms of the Agreement and there will be no further review by the Board. (If No, explain
below.)
3. Do you understand that once the approval of the Section 32 Waiver Agreement becomes final, the agreement can only be
modified upon a written request signed by all parties and approval by the Board? This means that changes can be made to the
Agreement, after approval becomes final, only if all parties agree and sign a written request and the request is approved by the
Board. (If No, explain below.)
4. Do you understand that you do not have to settle your claim? (If No, explain below.)
5. Do you understand that by settling your claim with a Section 32 Waiver Agreement, unless the Agreement allows for future
medical benefits, any future medical expenses related to your case will become your responsibility? This means that, if your
condition gets worse or you need surgery, for example, in the future, the insurance carrier will not authorize or pay for any more
treatment, medications or surgery. (If No, explain below.)
6. If you are currently receiving weekly payments, do you know when your payments will stop? (If No, explain below.)
7. Do you understand that once the approval of the Section 32 Waiver Agreement becomes final your case cannot be reopened to
address any issue that has been resolved by the Agreement? (If No, explain below.)
8. Do you agree with the amount of the settlement and understand that it was offered as a final settlement for the resolution of
these issues in your case? (If No, explain below.)
9. Do you agree with the amount of the fee requested by your attorney or licensed representative? The Board may approve or
modify the amount of the requested fee. (If No, explain below.)
10. Do you understand that any outstanding child support liens will be deducted from your settlement and paid in full up to the
amount of the Section 32 Waiver Agreement? (If No, explain below.)
11. Do you understand that once approval for the Section 32 Waiver Agreement becomes final and conclusive the insurance carrier
has 10 calendar days (if no party withdrew from the Agreement) to send the settlement check? This means that if your check is
not sent (postmarked) on or before the 10th day, after approval for the Agreement becomes final and conclusive, you may
request that the Board assess a penalty against the carrier. If the 10th day is a Saturday, Sunday or legal holiday, the carrier has
until the next business day to send your check. (If No, explain below.)
12. Have you made any promises, or have any promises been made to you, that are not reflected in this Section 32 Waiver
Agreement? (If Yes, explain below.)
13. Have you watched the required video: Settling Your Claim? The video provides an understanding of a Section 32 Waiver
Agreement and its implications. You may view the Settling Your Claim video at the following link: www.wcb.ny.gov/Section32
.
(If No, explain below.)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes
No
Yes
No
Yes
No
Yes No
Yes No
Yes No
Yes No
Explanation(s):
I affirm, under penalty of perjury, that the information provided above is true and accurate.
Claimant's Signature
Notary Public
Sworn to before me this
day of , 20
Date
C-32.1 (2-16) Page 2 of 2 www.wcb.ny.gov
Attorney Signature
Printed Name of Attorney
Date
I hereby attest that:
1. I represent the claimant, .
2. Prior to the execution of the WCL § 32 Waiver Agreement (Agreement), consideration was taken of Medicare's interests related to future medical services and whether the Agreement
should include a Workers' Compensation Medicare set-aside. I have discussed the need to consider Medicare's interests with my client.
3. I have thoroughly reviewed the Agreement executed by my client and submitted to the Board for approval, and have explained all aspects of the agreement to my client, including the
impact the Agreement, if approved, will have on my client's entitlement to further casually related medical treatment.
4. I afforded my client the opportunity to pose questions concerning the Agreement and have answered those questions to the best of my ability.
5. I have advised my client of the amount of the fee I intend to request from the proceeds of the Agreement and explained to my client the basis of the fee.
6. I have, to the best of my ability, ascertained and determined that my client fully understands the terms of the Agreement, the impact the Agreement will have on him/her if approved, and
that my client entered into the agreement of his/her own free will.
7. There are no outstanding issues in this/these claim(s) which are not fully resolved by the terms of that Agreement, except for those issues expressly left open by the Agreement.
8. I have, to the best of my ability, ascertained and determined that the address for my client on page one of this document is the claimant's current address, and that the settlement check
should be sent to that address.
