North Carolina > Workers Comp
Denial Of Workers Compensation Claim 61 - North Carolina
| Denial Of Workers Compensation Claim Form. This is a North Carolina form and can be used in Workers Comp . |
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North Carolina Industrial Commission IC File # DENIAL OF WORKERS COMPENSATION CLAIM Emp. Code # (G.S. 97-18(c) AND G.S. 97-18(d)) 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 Numb er Address Employers Address City State Zip City State Zip Insurance Carrier Policy Number ( ) - ( ) - Home Telephone Work Telephone Carriers Address City State Zip - - M F / / ( ) - ( ) - Social Security Number Sex Date of Birth Carriers Telephone Number Fax Number TO EMPLOYEE (TO DEPENDENT(S ) OR NEXT OF KIN IN CASE OF DEATH): This is to inform you that the claim for the injury on , or occupational disease as of , or death on is DENIED for the following reasons: / / SIGNATURE EMPLOYER OR CARRIER/ADMINISTRATOR TITLE DATE Employer/Insurance Carrier must provide a detailed statement of the grou nds for denying compensability of the claim or liability for the claim where payments have previously been made without prejudice under N.C. Gen. Stat. 97-18(d). Failure to specify a particular ground may preclude asserting certain defenses at a later date pursuant to N.C. Gen. Stat. 97-18(f). Employee: If you disagree with this denial, you are entitled to request a hearing by submitting a Form 33. If you need assistance you may contact the Industrial Commission at the address belo w or telephone the Industrial Commission at (800) 688-8349. Employer: A copy of this form shall be sent to the employee and employee s attorney of record, if any, and all known health care providers which have submitted bills to the employer/carrier. The o riginal of this form shall be sent to the Industrial Commission at the address below. MAIL TO: NCIC - CLAIMS S ECTION 4335 MAIL S ERVICE CENTER FORM 61 R ALEIGH, NC 27699-4335 10/04 PAGE 1 OF 1 FORM 61 MAIN TELEPHONE: (919) 807-2500 OMBUDSMAN: (800) 688-8349 American LegalNet, Inc. www.USCourtForms.com
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