New York > Workers Compensation
Section 32 Settlement Agreement Claimant Release C-32.1 - New York
| Section 32 Settlement Agreement Claimant Release Form. This is a New York form and can be used in Workers Compensation . |
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State of New York WORKERS' COMPENSATION BOARD SECTION 32 SETTLEMENT AGREEMENT: CLAIMANT RELEASE CLAIMANT'S NAME (PRINT) WCB CASE NUMBER(S) After reviewing and signing the final Section 32 Settlement Agreement, claimant must complete this document and have it notarized. In order to expedite the processing of the Agreement, this document must be submitted to the Board along with the Section 32 Agreement (Form C-32). See the reverse side for more information about the Section 32 process. 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 the Section 32 agreement, if approved by the Board, is binding on you and all the YES other parties and may not be appealed to either the Board or the Courts? (If No, explain below.) NO 2. Do you understand that once the agreement has been approved by the Board and the ten day waiting YES period has expired, the agreement cannot be withdrawn, modified, or reopened, and that the only way an approved agreement can be revisited is upon a written request to the Board, with the approval of all parties to the agreement, and the approval of the Board? (If No, explain below.) 3. Have you been placed in any duress in order to accept this agreement? (If Yes, explain below.)................. YES 4. Have you been made any promises that are not reflected in this agreement? (If Yes, explain below.) ......... YES 5. Are there any outstanding liens on your claim(s) (such as child support, taxes, spousal maintenance, or YES attorney fees)? (If Yes, explain below.) 6. Do you understand that you have the right to litigate your workers' compensation claim(s), and that you do YES not have to settle your claim(s)? (If No, explain below.) 7. Do you understand and accept the amount of the settlement? (If No, explain below.).................................. YES 8. Do you agree to the fee requested by your attorney or licensed representative with the understanding that YES the Board has the authority to approve, disapprove, or modify the fee requested? (If No, explain below.) 9. Do you understand that when this agreement becomes final, any future medical expenses related to this YES claim may become your responsibility? (If No, explain below.) 10. Have any doctor/hospital bills related to this claim been paid by anyone other than your employer or the YES workers' compensation insurance carrier? (If Yes, explain below.) Explanation(s): NO NO NO NO NO NO NO NO NO I affirm, under penalty of perjury, that the information provided above is true and accurate. _________________________________________________________________________ Claimant's Signature (ink only -- use blue ballpoint pen if possible) ____________________ Date Sworn to before me this ________________________day of ___________________________________, 20______ _________________________________________________ Notary Public C-32.1 (1-11) American LegalNet, Inc. www.FormsWorkFlow.com 12 NYCRR 300.36 Section 300.36 Section 32 agreements Statement of purpose. To encourage the parties in interest to enter into agreements settling upon and determining the compensation and other benefits due to the claimant or the claimant's dependents. (a) The parties in interest to a claim for compensation may settle upon and determine any and all issues and matters by agreement, in accordance with section 32 of the Workers' Compensation Law, subject to the terms and conditions of this rule. (b) Any agreement submitted to the board for approval shall be on a form prescribed by the chair or, alternatively, contain the information prescribed by the chair. (c) The receipt of an agreement by the board for approval shall act as a stay on all related proceedings before the board. (d) An agreement submitted pursuant to section 32 of the Workers' Compensation Law shall not be binding on the parties in interest unless it is approved by the chair, a designee of the chair, a member of the board, or a Workers' Compensation Law Judge. The agreement shall be approved unless it is determined that: (1) the agreement is unfair, unconscionable, or improper as a matter of law; or (2) the agreement is the result of an intentional misrepresentation of a material fact; or (3) within 10 days of submission of the agreement, the board has received from any party in interest a written request that the agreement be disapproved by the board. (e) The agreement shall be reviewed by the chair, a designee of the chair, a member of the board, or a Workers' Compensation Law Judge, who will make a determination whether to approve or disapprove the agreement. The chair, designee of the chair, member of the board, or Workers' Compensation Law Judge reviewing the agreement may approve or disapprove the agreement administratively, based on a review of the record before the board, or may choose to schedule a meeting to question the parties about the agreement. If the agreement is reviewed administratively, the Board shall advise the parties in writing of the date the agreement shall be deemed submitted for the purposes of section 32 of the Workers' Compensation Law and this section. If a meeting is scheduled to question the parties about the agreement, the agreement will be deemed submitted for the purposes of Section 32 of the Workers' Compensation Law and this section at such meeting. No agreement shall be approved for a period of 10 calendar days after submission to the board. (f) The board will advise the parties of the approval or disapproval of all agreements by duly filing and serving a notice of approval or disapproval. (g) An agreement which is approved shall be final and conclusive on the parties in interest, and shall not be subject to review pursuant to section 23 of the Workers' Compensation Law. An agreement which is disapproved shall be subject to review pursuant to section 23 of the Workers' Compensation Law. (h) The carrier shall make payments of any award as required in the agreement within 10 days of the filing of the decision approving the agreement. If the carrier fails to make s
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