North Carolina > Workers Comp
Report Of Employer Or Carrier Administrator Of Compensation And Medical Compensation 28C - North Carolina
| Report Of Employer Or Carrier Administrator Of Compensation And Medical 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 # REPORT OF EMPLOYER OR CARRIER /ADMINISTRATOR OF Emp. Code # COMPENSATION AND MEDICAL COMPENSATION PAID Carrier Code # PURSUANT TO A COMPROMISE SETTLEMENT AGREEMENT Carrier File # The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act Employer FEIN THIS FORM IS ONLY TO BE USED IN SETTLED CASES ( ) Employees Name Employers Name Telep hone Number Address Employers Address City State Zip City State Zip Insurance Carrier ( ) ( ) Home Telephone Work Telephone Carriers Address City State Zip M F / / ( ) ( ) Social Security Number Sex Date of Birth Carriers Telephone Number Fax Number 1. Date of accident or disability from occupational disease _______________ _________________________. 2. Salary was / was not continued. Total Dollar Amount 3. Number of weeks temporary total _____ from ______________ , through ______________ $______________ _____ from ______________ , through ______________ $______________ 4. Number of weeks temporary partial _____ from ______________ , through ______________ $______________ _____ from ______________ , through ______________ $______________ 5. Number of weeks permanent partial _____ from ______________ , through ______________ $______________ 6. Disfigurement amount paid $______________ 7. Loss of organ or body part benefits paid $______________ 8. TOTAL OF LINES 3 THROUGH 7 $______________ 9. Compromise Settlement Agreement amount $______________ 10. Total Medical Paid $______________ NAME OF EMPLOYER OR CARRIER/ADMINISTRATOR SIGNATURE TITLE DATE This form must be filed with the Industrial Commission at the address belo w. FOR INDUSTRIAL COMMISSION USE ONLY Days ____________________ Compensation Paid $____________________ Medical $____________________ IC Code: ____________________ FORM 28C MAIL TO: NCIC - STATISTICS S ECTION 11/2003 4334 MAIL S ERVICE CENTER PAGE 1 OF 1 R ALEIGH, NORTH CAROLINA 27699-4334 MAIN TELEPHONE : (919) 807-2500 OMBUDSMAN: (800) 688-8349 FORM 28C American LegalNet, Inc. www.USCourtForms.com
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