Establishing secure connection…Loading editor…Preparing document…

New York Waiver

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Form WD-5 (Waiver and Consent for Insurance Company)

NOTE: If the action was settled with the assistance of the Supreme Court, or if the amount of the settlement has been otherwise approved, this form will not be required.

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF

--------------------------------------------------------------------------X

In the Matter of the Application of

as

Administrat of the Goods,

Chattels and Credits which were of

, deceased,

for leave to compromise a certain cause of action

for wrongful death of the decedent and to render and

have judicially settled an account of the proceedings

as such Administrat.

WAIVER AND CONSENT
FOR INSURANCE COMPANY

FILE #

--------------------------------------------------------------------------X

TO THE SURROGATE’S COURT:

The Insurance Company, with offices at

as the insurer of and pursuant to its obligations to its insured under said liability insurance policy, does hereby appear and waive issuance and service of a citation in the above entitled proceeding. It further consents to pay the sum of

$ in full settlement of the claim for wrongful death of , deceased.

It further consents that the filing of a bond or other security be dispensed with and waive any further notice.

DATED:

Insurance Company

BY:

STATE OF NEW YORK )

COUNTY OF )ss:.

On the day of , 20, before me personally came and appeared , known to me to be a Corporate Officer of the Insurance Company, to wit, , who had the authority and who did execute the foregoing Waiver and Consent on behalf of the Insurance Company and acknowledged that executed the same.

Notary Public

Commission Expires:

(Affix Stamp)

Enter text✕

What the New York Waiver Is and when it applies

A New York Waiver is a written release or liability waiver used to document a party's voluntary relinquishment of specified claims, permissions, or rights under New York law. It commonly appears as a participant release for events, service-provider liability waivers, or contractual disclaimers attached to a larger agreement. Electronic execution is permitted under federal ESIGN (15 U.S.C. §7001) and New York's Electronic Signatures and Records Act (NY Tech Law §301–309), subject to exceptions like wills and certain court filings. Properly completed waivers clarify risk allocation and evidence informed consent.

Why a clear, compliant New York Waiver matters

A properly drafted and executed New York Waiver reduces ambiguity about assumed risks, supports enforceability in court, and documents informed consent. Using clear language, correct parties, and reliable signature records strengthens legal defensibility while streamlining event and program intake.

Why a clear, compliant New York Waiver matters

Who typically completes or requests a New York Waiver

Organizations and individuals use New York Waivers where activities or services carry measurable risk and consent or release is required.

  • Event organizers and venues handling recreational or athletic activities for the public.
  • Healthcare and wellness providers collecting treatment or program consent from patients or participants.
  • Commercial service providers and property owners requiring liability releases before access or participation.

Identify the role that applies to your situation — responsibilities differ for hosts, participants, and legal representatives.

Step-by-step: completing the New York Waiver

Follow a consistent order to minimize errors and make the form enforceable.

  • 01
    Prepare: Identify parties, scope, and the specific risks being released.
  • 02
    Fill core fields: Enter legal names, effective date, and clear release language.
  • 03
    Signers authenticate: Collect signature, printed name, and date from each signer.
  • 04
    Record retention: Store the executed waiver with an audit trail and copies.

Essential elements to include in a professional New York Waiver

A complete waiver combines plain-language risk description, explicit release language, and signer identification to form a defensible record.

Clear Release

Plain-language clause stating which claims are waived, including the scope and limitations. Ambiguous wording can nullify intended protections.

Defined Parties

Full legal names of the releasor and releasee. If entities, include corporate designation (Inc., LLC) and authorized signer details.

Specific Risks

List or describe foreseeable risks and hazards related to the activity so signers understand what they are waiving.

Consideration Clause

Document what the signer receives in exchange for the waiver — admission, services, or reduced fees — to support contract formation.

Compliance Note

State that electronic execution is valid under ESIGN and NY ESRA when applicable, and note any required disclosures or exceptions.

Record Details

Include signature date, printed name, signer contact, and witness/notary details if required for the specific transaction.

Required data points to collect and secure

Signer Name: Full legal name
Signature: Handwritten or electronic
Date Signed: MM/DD/YYYY
Contact Info: Email or phone
Minor Details: Child name and DOB
Authentication: Method used

Key legal risks and consequences of an incorrect waiver

Unenforceable: Ambiguous language
Personal Liability: Undischarged claims
Insurance Denial: Coverage disputes
HIPAA Exposure: Unauthorized PHI disclosure
Contract Voidance: Lack of consideration
Regulatory Penalty: Statutory noncompliance

Common preparation mistakes to avoid with waivers

  • Using overly broad or vague release language that fails to identify specific risks and activities.
  • Collecting signatures without recording authentication method, timestamp, or signer contact for later verification.
  • Failing to obtain guardian signatures for minors or to state explicit minor participant details.
  • Relying on a scanned signature image without an accessible audit trail linking the signature to the signer.

How electronic completion and delivery typically works

A consistent digital workflow reduces friction while preserving legal evidence of consent and execution.

  • Upload: Sender uploads waiver document for distribution.
  • Place Fields: Add signature, date, and required input fields.
  • Send: Distribute via email link or bulk send.
  • Audit: System records timestamp, IP, and actions.

Digital signing and platform compatibility

Electronic waivers require a platform that preserves an audit trail and supports required authentication.

  • File formats: PDF, DOCX supported
  • Integrations: CRM and cloud storage
  • Authentication: Email, SMS, MFA

Suggested settings when creating an online waiver workflow

Configure fields and authentication to match the waiver's risk profile and the signers' needs.

Field Configuration
Signer Order Specified order or parallel signing options
Authentication Email link, SMS code, or higher-assurance KBA
Conditional Fields Show additional fields for minors or special conditions
Retention Auto-save signed PDF with audit certificate

Timing and processing expectations for waivers

Plan signing and retention steps around event schedules and regulatory needs to avoid lapses in coverage or enforceability.

Before Participation:

Obtain a signed waiver prior to event attendance or service delivery

Immediate Record:

Save a signed copy and audit trail immediately after execution

Minor Consent Timeline:

Ensure parent/guardian signs and records relationship before minors participate

Revocation Handling:

Document any revocation request and retain correspondence

Periodic Review:

Review waiver language annually or on material process change

Comparing signNow with other eSignature vendors for waiver workflows

Basic pricing and compliance features for common eSignature solutions. Choose a vendor based on volume, authentication needs, and regulatory obligations.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes, 7-day trial Yes (varies) Yes (varies) Yes (varies) Yes (varies)
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently asked questions about New York Waivers

Answers to common practical and legal questions when preparing, signing, or storing a New York Waiver.


Need help? Contact support

be ready to get more
Join over 28 million airSlate SignNow users