North Carolina Industrial Commission IC File # NOTICE OF REINSTATEMENT OR MODIFICATION OF COMPENSATION (G.S. § 97-32.1 OR § 97-18(b)) The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Emp. Code # Carrier Code # Carrier File # Employer FEIN Employee's Name Address City ( ) Home Telephone XXX-XXLast 4 Digits of SSN Date of Injury: State ( ) Work Telephone // Date of Birth Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address ( ) Carrier's Telephone Number City ( ) Telephone Number State Zip Policy Number City ( ) State Zip M Sex F Fax Number . Compensation in the amount of $ pursuant to per week was reinstated or modified on N.C. Gen. Stat. § 97-32.1 or N.C. Gen. Stat. § 97-18(b). Give reason for reinstatement: The employee's average weekly wage, including overtime and all allowances, was . which results in a weekly compensation rate of $ . a. Temporary total compensation is being paid at the compensation rate above. . 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 employee's attorney of record, if any. FILE VIA ELECTRONIC DOCUMENT FILING PORTAL FORM 62 02/2017 PAGE 1 OF 1 HTTP://WWW.IC.NC.GOV/DOCFILING.HTML CONTACT INFORMATION: FORM 62 NCIC-CLAIMS ADMINISTRATION TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com
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