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Stipulation C-300.5 - New York
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State of New York WORKERS' COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. STIPULATION WCB CASE NO.(S) DATE(S) OF ACCIDENT CLAIMANT (PLEASE PRINT) CARRIER CASE NO. CARRIER CODE CARRIER (Please Print) EMPLOYER (Please Print) OTHER PARTY-IN-INTEREST (Please Print) The undersigned parties to the action herein stipulate to the following facts or proposed findings in the above captioned Workers' Compensation case (12NYCRR300.5). This stipulation shall be entered upon the record of this proceeding and, if accepted, shall be incorporated into the decision of the WC Law Judge. THE UNDERSIGNED HEREBY CONSENT TO THE ABOVE AND ACKNOWLEDGE RECEIPT OF A COPY OF THIS STIPULATION. IF THE CLAIMANT IS UNREPRESENTED, THIS FORM MUST BE SIGNED IN THE PRESENCE OF THE WC LAW JUDGE. CLAIMANT (Signature) By: CARRIER OR SELF-INSURED EMPLOYER (Please Print) By: PARTY (Please Print) WC LAW JUDGE (Signature) (Signature) DATE (Signature) ATTORNEY OR LIC. REPRESENTATIVE (Signature) C-300.5 (7-97) SEE IMPORTANT INFORMATION ON THE REVERSE 2001 © American LegalNet, Inc. 12 NYCRR 300.5 Decisions by Workers' Compensation Law Judges: (a) In controverted claims the Workers' Compensation Law Judge shall make a reasoned decision upon the contested points. This decision, outlining the evidence supporting said determination, may be made by an oral statement which shall be entered upon the minutes of the hearings, or may be in a written and signed statement which shall be filed with the papers in the record. (b) (1) Parties to any claim before the board may stipulate to uncontested facts or proposed findings. Such stipulation shall be in writing and shall be signed by all parties so stipulating. A Workers' Compensation Law Judge shall verify through questioning that all parties: (i) have been advised of the legal effect of stipulating to the facts or proposed findings contained in said stipulation; and (ii) have affixed their signatures to said stipulation of their own free will. If the claimant is not represented, the stipulation shall be signed in the presence of a Workers' Compensation Law Judge. (2) A stipulation pursuant to this section shall be subject to the approval of a Workers' Compensation Law Judge and, if approved, shall be incorporated into the decision of the Workers' Compensation Law Judge and shall be binding upon the parties. Such stipulation, as incorporated into the decision of the Workers' Compensation Law Judge, shall be subject to the provisions of section 23 of the Workers' Compensation Law and section 300.13 of this Part, and to sections 22 and 123 of the Workers' Compensation Law. (3) The provisions of this subdivision shall not be applicable to agreements settling upon and determining claims for compensation pursuant to section 32 of the Workers' Compensation Law and section 300.36 of this Title. C-300.5 (7-97) Reverse 2001 © American LegalNet, Inc.