North Carolina > Workers Comp
Intervenors Request That Claim Be Assigned For Hearing 33I - North Carolina
| Intervenors Request That Claim Be Assigned For Hearing Form. This is a North Carolina form and can be used in Workers Comp . |
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NORTH CAROLINA INDUSTRIAL COMMISSION IC File # ______________ INTERVENOR'S REQUEST THAT CLAIM BE ASSIGNED FOR HEARING (N.C. GEN. STAT. §97-26(i)) A. INTERVENOR/MEDICAL PROVIDER INFORMATION Medical Provider Date(s) of Service Total Charges for Services Provided Contact Name Address City State Zip ( Email ) - ( ) Fax - Telephone B. EMPLOYEE/CLAIMANT Employee's Name Address City State Zip C. EMPLOYER/CARRIER INFORMATION ( ) Employer's Name Employer's Address Insurance Carrier Adjustor Carrier's Address City State Zip City Telephone Number State Zip Policy Number ( - ) - Sex ( M F ) Work Telephone Home Telephone Social Security Number / / ( ) ( ) Carrier's Telephone Number Carrier's Fax Number Date of Birth The above-named Intervenor, _________________________ files notice that, pursuant to N.C. Gen. Stat. § 97-26(i) and Rule 24 of the North Carolina Rules of Civil Procedure, N.C. Gen. Stat. § 1A-1, it has been allowed a limited intervention in this matter by Order dated ________. The Intervenor and the parties above have failed to resolve a dispute regarding payment of charges for medical services indicated above and request a hearing. Name of Individual Receiving Services: ________________________ Date of Injury: _______________ Has Claim been: Admitted. Denied. Date of Denial: __________ Has a compromise settlement agreement been approved? Yes No Date Approved: _________ Has any party to this claim previously requested a hearing before the Industrial Commission? Yes No CERTIFICATION I, _____________________________________, hereby certify that this case is ready for hearing Print Name and request a hearing in Wake County or _______________ County. ___________________________________________ ____________ Signature of (Check One) Note: Attorney, Medical Provider/Intervenor MAIL TO: Date NCIC DOCKET SECTION 4336 MAIL SERVICE CENTER RALEIGH, NC 27699-4336 MAIN TELEPHONE: (919) 807-2500 HELP LINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV A copy of this form must be sent to opposing parties. The original of this form must be sent to the Industrial Commission at the address to the right. FORM 33I American LegalNet, Inc. www.FormsWorkFlow.com
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