Fillable SETTLEMENT AGREEMENT - Section 32 WCL Indemnity Only (New York State)

Fill Online, Printable, Fillable, Blank SETTLEMENT AGREEMENT - Section 32 WCL Indemnity Only (New York State) Form

Use Fill to complete blank online NEW YORK STATE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

SETTLEMENT AGREEMENT - Section 32 WCL Indemnity Only (New York State)

On average this form takes 23 minutes to complete

The SETTLEMENT AGREEMENT - Section 32 WCL Indemnity Only (New York State) form is 3 pages long and contains:

  • 0 signatures
  • 26 check-boxes
  • 79 other fields

Country of origin: US
File type: PDF

Free fillable forms for New York State

BROWSE NEW YORK STATE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
SETTLEMENT AGREEMENT - Section 32 WCL
Indemnity Only Settlement Agreement
C-32-I (6-20) Page 1 of 3
WCB CASE NO.
CARRIER CODECARRIER CASE NO.
DATE OF ACCIDENT CLAIMANT'S NAME (Please Print)
CLAIMANT'S ADDRESS (Please Print)
EMPLOYER (Please Print) CARRIER (Please Print)
This Agreement is prepared and submitted pursuant to Section 32 of the Workers' Compensation Law. By signing below, each party to the
Agreement affirms that (s)he has read and understands its provisions, and understands that the Agreement, if approved by the Workers'
Compensation Board, is conclusive, final and binding on all the parties involved.
By this Agreement, the parties settle upon and determine some, but not all, issues and matters to the Claim.
WCB Case No.
is:
not accepted by the carrier, nor is liability established. The parties agree that upon the approval of this Agreement,
carrier, nor is liability established. The parties agree that upon the approval of this Agreement, WCB Case No.
a claim for the following injuries: , which is not accepted by the
will be established for the following injuries:
will be withdrawn.
WCB Case No.
established for the following injuries:
WCB Case No.
is:
not accepted by the carrier, nor is liability established. The parties agree that upon the approval of this Agreement,
carrier, nor is liability established. The parties agree that upon the approval of this Agreement, WCB Case No.
a claim for the following injuries: , which is not accepted by the
will be established for the following injuries:
will be withdrawn.
WCB Case No.
established for the following injuries:
WCB Case No.
is:
not accepted by the carrier, nor is liability established. The parties agree that upon the approval of this Agreement,
carrier, nor is liability established. The parties agree that upon the approval of this Agreement, WCB Case No.
a claim for the following injuries: , which is not accepted by the
will be established for the following injuries:
will be withdrawn.
WCB Case No.
established for the following injuries:
WCB Case No.
is:
not accepted by the carrier, nor is liability established. The parties agree that upon the approval of this Agreement,
carrier, nor is liability established. The parties agree that upon the approval of this Agreement, WCB Case No.
a claim for the following injuries: , which is not accepted by the
will be established for the following injuries:
will be withdrawn.
WCB Case No.
established for the following injuries:
PO Box 5205, Binghamton, NY 13902-5205
www.wcb.ny.gov
The parties to this WCL Section 32 Waiver Agreement (Agreement), the Claimant and the Carrier hereby agree:
1. Claims Subject to Agreement
per week.
Initials:
Claimant: Carrier:
( / / ); ( / / )
The Claimant was classified with a permanent partial disability (PPD). Awards are continuing at the rate of
$
per week.
The Claimant was classified with a permanent total disability (PTD). Awards are continuing at the rate of
$
If necessary, attach additional sheets listing cases subject to this agreement.
Select if applicable:
2. Indemnity Benefits
a. Weekly Payments Made to Date the Agreement in Finally Approved by the Board
If the Carrier is under a direction to pay continuing benefits, the Carrier agrees to make further payments until the date of the
Agreement is finally approved by the Board. Weekly benefit payments will thereafter cease.
b. Prior Temporary Rates Made Permanent
Prior tentative rates, if any, are made permanent. Prior periods, if any, for which no payments were previously made are deemed
periods of no compensable lost time and no reduced earnings.
c. Overpayment (Check One)
from the net recovery to the claimant noted below.
The Carrier agrees to waive any overpayment, if applicable.
The Carrier may recoup its overpayment in the amount of $
3. No Waiver of Medical Treatment
The claimant has not waived, and will remain entitled to, medical treatment for established injuries in the claims which are subject to
this agreement, subject to the provisions of the New York State Workers' Compensation Law. The Workers' Compensation Board shall
retain jurisdiction to re-open this case solely to adjudicate any such issues relating to medical treatment and liability for such treatment.
4. Waiver of Indemnity Benefits
Upon final approval of the Agreement by the Board, except for payments called for in this Agreement, Claimant waives any and all
rights to further indemnity benefits under the Workers' Compensation Law with respect to the claims which are subject to this
agreement.
CLAIMANT'S NAME:
CARRIER CASE NO.:
WCB CASE NO.:
C-32-I (6-20) Page 2 of 3
Initials:
Claimant: Carrier:
( / / ); ( / / )
5. Settlement Amount (Check One)
In return for the Claimant's waiver of his/her right to future indemnity benefits, upon final approval of the Agreement, the Carrier
agrees to pay the Claimant the amount of $ _______________, less a fee of $ _______________, payable to the claimant's
attorney, subject to approval of the fee by the Workers' Compensation Board. Claimant's attorneys agree to waive any previously
awarded but unpaid attorney fees as of the date the Agreement is finally approved by the Board.
In return for Claimant's waiver of his/her right to future indemnity benefits, upon final approval of the Agreement, the Carrier agrees
to pay the Claimant the amount of $ _______________ within ten (10) days of the approval of the Agreement by the Board, less a
fee of $ _______________, payable to the Claimant's attorney, subject to approval of the fee by the Workers' Compensation
Board. Claimant's attorneys agree to waive any previously awarded but unpaid attorney fees as of the date of the Agreement is
finally approved by the Board. In addition, the carrier agrees to make periodic payments to the claimant as follows:
_______________________________________________________________________________________________________.
6. Child Support Arrears (Check One)
Claimant does not have any overdue child support obligations (arrears).
The Carrier will fund the periodic payments by purchasing an annuity as set forth in Appendix A of the Agreement.
Claimant owes child support arrears which will be paid in full from the proceeds of the Agreement.
The Carrier will forward payment of funds to satisfy the child support arrears directly to the appropriate payee.
Claimant owes child support arrears which exceed the amount payable to the claimant pursuant to the Agreement.
The full amount of the settlement payable to the claimant will be forwarded by the carrier to the appropriate payee to partially
satisfy the child support arrears owed by the claimant.
CLAIMANT'S NAME:
CARRIER CASE NO.:
WCB CASE NO.:
C-32-I (6-20) Page 3 of 3
Initials:
Claimant: Carrier:
( / / ); ( / / )
The undersigned hereby consent of their own free will to be subject to the above provisions, terms and conditions
and acknowledge receipt of a copy of this Agreement.
CLAIMANT - PLEASE PRINT
CARRIER OR SELF-INSURED EMPLOYER - PLEASE PRINT
ATTORNEY - PLEASE PRINT
CLAIMANT SIGNATURE DATE
CARRIER OR SELF-INSURED EMPLOYER SIGNATURE DATE
ATTORNEY SIGNATURE DATE
OTHER - PLEASE PRINT
OTHER SIGNATURE DATE
7. Third-Party Action (Lien)
The carrier reserves it right to assert a lien pursuant to WCL Section 29 based on all indemnity and medical benefits paid to claimant
pursuant to the Workers' Compensation Law with respect to the claims which are subject to this Agreement, including the proceeds
payable to claimant pursuant to this Agreement, against any third-party recovery obtained by the claimant.
8. Appeals
Upon approval of the Agreement by the Board, any pending application for administrative review of a decision of a Workers'
Compensation Law Judge or Full Board Review, filed by any party to this Agreement, insofar as the application pertains to the award
of indemnity benefits, is hereby withdrawn.
9. Other Terms
Include any other terms that are included in the Agreement
(attach additional sheets, if necessary).
CONSENT FOR DESK REVIEW
CONSENT FOR DESK REVIEW
CONSENT FOR DESK REVIEW
CONSENT FOR DESK REVIEW
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

SETTLEMENT AGREEMENT - Section 32 WCL Indemnity Only (New York State)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document