North Carolina > Workers Comp
Application For Lump Sum Award 31 - North Carolina
| Application For Lump Sum Award Form. This is a North Carolina form and can be used in Workers Comp . |
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North Carolina Industrial Commission IC File # APPLICATION FOR LUMP SUM AWARD Emp. Code # Carrier Code # Carrier File # The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act Employer FEIN ( )Employees Name Employers Name Telephone NumberAddress Employers Address City State Zip City State ZipInsurance Carrier ( ) ( ) Home Telephone Work Telephone Carriers Address City State Zip M F / /( ) ( )Social Security Number Sex Date of Birth Carriers Telephone Number Fax NumberAPPLICATION MUST BE COMPLETED IN FULL BEFORE REQUEST WILL BE CONSIDERED. The applicant represents that he or she has been granted an award of compensation by the North Carolina Industrial Commission, and that the award has been paid in periodical payments for not less than six weeks. The applicant hereby requests that he or she beallowed a lump-sum payment in an amount as requested below. (If the applicant desires to buy property of any kind with this lump sumsettlement, three estimates of the value of the property must be submitted with the application to the Industrial Commission.) Name: Present Employer: How Long: Address: Job Title: Average Wage/Wk : Are you unemployed: Birth Date: Other Income (Including Spouses): Phone Number: Marital Status: Dependents (Names & Ages): Outstanding Bills (Creditor and Amount Owed): Purpose of Lump Sum Request: Amount Requested $ Applicants Signature: Date: Applicant must send a copy of this form to the carrier and a copy to the Industrial Commission at the address below. TO BE COMPLETED BY CARRIER/ADMINISTRATOR The (Name Insurance Company), agrees to pay the requested amount of $ in a lump sum without commutation, or agrees to pay the following recommended amount of $ in a lump sumwithout commutation or refuses to pay the compensation in a lump sum without commutation. Balance due applicant (pre-lump sum): For Commissions Use Only Approved By: Amount: Signature TitleDenied By: Date: MAIL TO: NCIC - CLAIMS S ECTION 4335 MAIL S ERVICE CENTER FORM 31 R ALEIGH, NC 27699-4335 2/01 FORM 31 MAIN TELEPHONE: (919) 807-2500 PAGE 1 OF 1 OMBUDSMAN: (800) 688-8349
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