Free Section 32 Waiver Agreement Template
Section 32 Waiver Agreement
This Section 32 Waiver Agreement ("Agreement") is entered into as of the 6th day of January 2050, by and between:
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Claimant: John Doe, residing at 123 Elm Street, Springfield, NY 12345.
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Employer: [Your Company Name], with a principal place of business at [Your Company Address].
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Insurance Carrier: Reliable Insurance Co., having its principal place of business at 789 Insurance Plaza, Capital City, NY 11223.
WHEREAS:
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The Claimant sustained injuries on or about March 15, 2049, in the course and scope of employment with the Employer.
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A claim for workers' compensation benefits was filed under Claim Number WC-2050-00123 with the New York State Workers’ Compensation Board.
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The parties desire to resolve all issues and disputes arising out of this claim without further litigation or administrative proceedings.
1. Settlement Amount
The Insurance Carrier agrees to pay the Claimant a lump sum of One Hundred Fifty Thousand Dollars ($150,000) in full and final settlement of all claims arising under this workers' compensation case.
2. Waiver of Rights
By signing this Agreement, the Claimant waives any rights to future benefits, including but not limited to medical benefits, wage replacement benefits, and any other compensation under the Workers' Compensation Law, related to the injuries sustained on March 15, 2049.
3. No Admission of Liability
This Agreement shall not be construed as an admission of liability by the Employer or Insurance Carrier. The settlement is entered into solely to resolve disputed claims.
4. Approval by Workers' Compensation Board
This Agreement is subject to the approval of the New York State Workers’ Compensation Board. The parties agree to submit this Agreement for approval within 30 days of execution.
5. Representation and Acknowledgment
The Claimant represents that:
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They have been fully advised by their attorney, Jane Smith of Smith & Associates Law Firm, or have waived the right to legal counsel.
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They understand the terms and conditions of this Agreement.
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They enter into this Agreement voluntarily, without coercion or duress.
6. Complete Agreement
This Agreement constitutes the entire understanding between the parties and supersedes all prior negotiations or agreements.
7. Execution
This Agreement may be executed in counterparts, each of which shall be deemed an original, but all of which together shall constitute the same instrument.
IN WITNESS WHEREOF, the parties have executed this Agreement as of the date first written above.
Claimant:
Name: John Doe
Date: January 6, 2050
Employer/Insurance Carrier Representative:
Name: [Your Name]
Title: Claims Manager
Date: January 6, 2050
Attorney for Claimant (if applicable):
Name: Jane Smith
Date: January 6, 2050
