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Get NY C-32 2021-2024

Special Funds must sign and date Form C-32 if 25-a has been found applicable to the case s. If a disability benefits lien is addressed in the Section 32 Waiver Agreement then the Disability Benefits Carrier must sign. 4. Other Necessary Documents Submit along with Form C-32 the following documents. Be sure to reference on the documents the WCB Case Number for each claim included in the Section 32 Waiver Agreement a signed and notarized Form C-32. Failure to follow these instructions and to provide the necessary accompanying documents may result in the resolution of the Section 32 Agreement being delayed. The statute and regulation pertaining to Section 32 Waiver Agreements WCL 32 and 12 NYCRR 300. 36 is available at www. wcb. ny. gov. 1. Form Submit a legible Form C-32. The terms of the agreement must be in a single separate attachment. THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION* WAIVER AGREEMENT - Section 32 WCL WCB CASE NO. S DATE S OF ACCIDENT CLAIMANT S NAME Please Print CLAIMANT S TELEPHONE area code CLAIMANT S ADDRESS Please Print CARRIER CASE NO. S CARRIER CODE S EMPLOYER S Please Print CARRIER S Please Print MEDICAL REMAINS OPEN TELEPHONE APPEARANCE REQUESTED if hearing is needed Contact number for telephone hearing include area code INTERPRETER NEEDED Type of Interpreter and Language Needed Other Parties of Interest Please indicate if any additional parties are signatories Additional Carrier s including DB carrier Uninsured Employer s Fund Beneficiary in a Death claim Guardian in a Minor claim Special Funds Waiver Agreement Management Office WAMO Section 32 Waiver Agreement Conditions Please indicate whether the waiver agreement settles all or some of the issues in the claim s Settles all issues and matters in the claim s identified by the WCB Claim number s above Settles some but not all issues and matters in the claim s identified by the WCB Claim number s above Liens Please check the appropriate box and provide the page number where the issue is addressed Child Support lien - see page s Supporting document from jurisdiction required Disability Benefits lien - see pages s Medical Please check the appropriate box and provide the page number where the issue is addressed Medical remains open - see page s CMS letter required - see page s WTCHP letter required - see page s Outstanding C-8. 1 Part B objection s - see page s Indemnity Please check the appropriate box and provide the page number where the issue is addressed Suspension of continuing payments - see page s Reinsurance Agreement - see page s Qualified Assignment - see page s Documentation required Other Pending appeal with the Board is withdrawn - see page s or if in CIS Document ID List any issues not mentioned in the above list that you would like the Board to consider and indicate the page s where the issue is addressed* 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.

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