North Carolina > Workers Comp
Notice To Employee Of Payment Of Compensation Without Prejudice 63 - North Carolina
| Notice To Employee Of Payment Of Compensation Without Prejudice Form. This is a North Carolina form and can be used in Workers Comp . |
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North Carolina Industrial Commission IC File # NOTICE TO EMPLOYEE OF PAYMENT OF COMPENSATION Emp. Code # WITHOUT PREJUDICE (G.S. 97-18(d)) Carrier File # Carrier Code # The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act Employer FEIN ( ) - Employees Name Employers Name Telephone 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 TO EMPLOYEE (TO DEPENDENT(S ) OR NEXT OF KIN IN CASES OF DEATH): This is to inform you with regard to your claim for injury on occupational disease as of death on , payments of workers compensation benefits will be made without prejudic e to deny your claim or our liability at a later time. This notice is not an admission of liability. Compensation may be continued during our current investigation of your c laim. Our investigation may take up to 90 days, with a possible 30 day extension. However, during this time we may accept liab ility; contest your claim or our liability; or by our lack of action waive our right to contest your claim or our liability. The date on which the employer first had written or actual notice of emp loyees injury or employees death was . The disability began on . The first payment will be made to you on . We understand that your average weekly wage, including overtime and all owances, is $ . . The rate of compensation (66 2/3 percent of the average weekly wage) is $ . . / / SIGNATURE EMPLOYER OR CARRIER/ADMINISTRATOR TITLE DATE EMPLOYER: A copy of this form shall be sent to the employee and the original of the form shall be sent to the INDUSTRIAL COMMISSION at the address below. If you need assistance, you may telephone the Industrial Commission at (800) 688-8349. Failure to file Form 28B, Report Of Compensation And Medical Compensation Paid, within 16 days after last payment pursuant to an agreement or award may subject the employer or carrier/administrator to a penalty. MAIL TO: NCIC - CLAIMS S ECTION FORM 63 4335 MAIL S ERVICE CENTER 10/04 R ALEIGH, NC 27699-4335 PAGE 1 OF 1 FORM 63 MAIN TELEPHONE: (919) 807-2500 OMBUDSMAN: (800) 688-8349 American LegalNet, Inc. www.USCourtForms.com
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