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Get NY C-312.5 2010-2024

D Claimants Only 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 have agreed to the findings and awards as indicated below, and pursuant to 12 NYCRR 312.5, request that they be incorporated into a proposed conciliation decision. If there is a meeting, the resulting proposed conciliation decision will become final and constit.

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