Carriers Or Self-Insured Employers Affirmation {C-32AF}

C-32AF - CARRIER'S/SELF-INSURED EMPLOYER'S AFFIRMATION. This form is filed as an attachment to the C-32 agreement. The person who signed the Section 32 Agreement on behalf of the carrier/self-insured employer is required to execute this form. They affirm under penalty of perjury that they have signed the Section 32 Agreement submitted to the Board for approval in the referenced claim on behalf of the carrier/self-insured employer, or its designated third-party administrator, and that the Agreement contains all the terms and conditions agreed to by and between the claimant and the carrier, and that no separate agreements or contracts have been entered into by the parties that are not reflected in the agreement submitted to the Board for approval. They further affirm that the carrier/self-insured employer has not, as a condition to the execution of the Section 32 Agreement, required that claimant enter into a separate agreement, now or in the future, waiving claims or rights that claimant may have in another jurisdiction or forum. www.FormsWorkflow.com