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Get Ny C-300.5 1997

STIPULATION WCB CASE NO.(S) DATE(S) OF ACCIDENT CARRIER CASE NO. CLAIMANT (PLEASE PRINT) CARRIER CODE CARRIER (Please Print) EMPLOYER (Please Print) OTHER PARTY-IN-INTEREST (Please Print) The undersigned parties to the action herein stipulate to the following facts or proposed findings in the above captioned Workers' Compensation case (12NYCRR300.5). This stipulation shall be entered upon the record of this proceeding and, if accepted, shall be incorporated into the decision of the WC La.

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