North Carolina > Workers Comp
Certification Of Payment Of Processing Fee For Compromise Settlement Agreements - North Carolina
| Certification Of Payment Of Processing Fee For Compromise Settlement Agreements Form. This is a North Carolina form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
I.C. No.__________, _________________, Employee, Plaintiff, v. __________________________, Employer, and _________________, Carrier, Defendants. CERTIFICATION OF PAYMENT OF PROCESSING FEE FOR COMPROMISE SETTLEMENT AGREEMENTS I hereby certify and attest that payment in the amount of $________________________ has been sent by _________________________________ on ____________________ (U.S. Mail or other method of delivery) (date) by _________________________________ by Check # ________________ (person or entity sending payment) as the processing fee for the Compromise Settlement to the North Carolina Industrial Commission. This the ____________ day of _____________, __________. ________________________________________________________________________ Signature of Certifier ________________________________________________________________________ Print Name Title of Certifier: _________________________________________________________ (attorney/adjuster/other) E-Mail address of Certifier: ________________________________________________ Other address information of Certifier: ________________________________________ Fax information of Certifier: ________________________________________________ Telephone number of Certifier: _____________________________________________ *This certification is required for Compromise Settlement Agreements and shall be included when a Compromise Settlement Agreement is sent by e-mail submission only. American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
