North Carolina > Workers Comp
Notice Of Reinstatement Or Modification Of Compensation 62 - North Carolina
| Notice Of Reinstatement Or Modification Of Compensation Form. This is a North Carolina form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
North Carolina Industrial Commission IC File # NOTICE OF REINSTATEMENT OR MODIFICATION OF Emp. Code # COMPENSATION (G.S. 97-32.1 OR 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 Te lephone Number 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 Compensation in the amount of $ . per week was reinstated or modified on pursuant to N.C. Gen. Stat. 97-32.1 or N.C. Gen. Stat. 97-18(b). Give reason for reinstatement: 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: . / / SIGNATURE EMPLOYER OR CARRIER/ADMINISTRATOR TITLE DATE Employer: The original of this form must be sent to the Industrial Commission at the address below. A copy shall be provided to the employee and the employees attorney of record, if any. MAIL TO: NCIC - CLAIMS S ECTION FORM 62 4335 MAIL S ERVICE CENTER 10/04 R ALEIGH, NC 27699-4335 PAGE 1 OF 1 FORM 62 MAIN TELEPHONE: (919) 807-2500 OMBUDSMAN: (800) 688-8349 American LegalNet, Inc. www.USCourtForms.com
|
|||||||
