North Carolina > Workers Comp
Employers Admission Of Employees Right To Compensation 60 - North Carolina
| Employers Admission Of Employees Right To Compensation Form. This is a North Carolina form and can be used in Workers Comp . |
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North Carolina Industrial Commission IC File # EMPLOYER S ADMISSION OF EMPLOYEE S RIGHT TO Emp. Code # COMPENSATION (G.S. 97-18(b)) 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: Your employer admits your right to compensation for an injury by accident on , or occupational disease as of . THE FOLLOWING ITEMS 1 THROUGH 4 ARE PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE AN AGREEMENT: 1. The description of the injury by accident or occupational disease is: 2. The employee was paid for the entire day of injury. Yes No 3. The employees average weekly wage, including overtime and all allowance s, was $ . , which results in a weekly compensation rate of $ . . a. Temporary total compensation is being paid at the compensation rate abov e. b. Temporary partial compensation is being paid in the amount of $ . c. Other: 4. The disability resulting from the injury began on , and compensation commenced on . / / SIGNATURE EMPLOYER OR CARRIER/ADMINISTRATOR TITLE DATE EMPLOYER: Failure to file Form 28B, Report of Compensation and Medical Compensation Paid, within 16 days after last payment pursuant to an agreement or award subjects employer or carrier/a dministrator to a penalty pursuant to N.C. Gen. Stat. 97-18(h). Form 30 must be used for compensable injuries resulting in dea th. A copy of this Form 60 shall be provided to the employee and the employees attorney of record, if any, and the original provided to the Industrial Commission at the address below. MAIL TO: NCIC - STATISTICS S ECTION FORM 60 4334 MAIL S ERVICE CENTER 10/04 PAGE 1 OF 1 R ALEIGH, NC 27699-4334 FORM 60 MAIN TELEPHONE: (919) 807-2500 OMBUDSMAN: (800) 688-8349 American LegalNet, Inc. www.USCourtForms.com
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