North Carolina > Workers Comp
Notice Of Award 30A - North Carolina
| Notice Of Award 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 OF AWARD Emp. Code # Employer FEIN Carrier File # The Use of This Form Is Required Under The Provisions of the Workers' Compensation Act. Carrier Code # ( Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address ) Telephone Number City State Zip ( ) (M) (F) ( / ) City State Fax Number Zip Home Telephone Social Security Number Sex Work Telephone / ( ) ( ) Date of Birth Carrier's Telephone Number The above parties have previously submitted an agreement for compensation for disability or death on Form . The Commission entered an award in the case upon receipt of the agreement. The Commission has now been informed that . Therefore, the original award is amended as follows: As above mentioned, said Agreement is hereby approved. This is a formal award of the Industrial Commission. Any interested party may give notice of appeal therefrom within fifteen (15) days or receipt of this award. SIGNATURE TITLE DATE FORM 30A 8/08 PAGE 1 OF 1 FORM 30A MAIL TO: NCIC - CLAIMS ADMINISTRATION 4335 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.COMP.STATE.NC.US/ American LegalNet, Inc. www.FormsWorkflow.com
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