Section 32 - Electronic Signature
State of New York - Workers' Compensation Board
C-32E (7-19) www.wcb.ny.gov
The insurance carrier, self-insured employer or third-party administrator:
(legal name of entity)
with its principal place of business located at the address indicated on the letterhead above and identified by the Workers'
Compensation Board in its system using the following identifier
Section 32 Agreement using an electronic signature process that meets the requirements set forth in the New York State
Electronic Signatures and Records Act (ESRA) and its accompanying regulations (9 NYCRR Part 540).
(W or other number)
has signed the attached
Section 32 Agreement:
Claimant Name:
WCB Case Number(s):
Date(s) of Accident:
Specifically the Section 32 Agreement has been signed using:
(describe method eg. DocuSign or Adobe Sign)
The undersigned affirms the foregoing and his or her authority to bind the insurance carrier or self-insured employer to
Section 32 Agreements electronically signed using the identified electronic signature.
Signed by:
Signature:
Print Name:
Title:
Email:
Phone Number:
Date:
