Denial Of Workers Compensation Claim {61}

North Carolina Industrial Commission IC File # DENIAL OF WORKERS' COMPENSATION CLAIM (G.S. § 97-18(c) AND G.S. § 97-18(d)) The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Emp. Code # Carrier Code # Carrier File # Employer FEIN ( ) Telephone Number City Policy Number City ( ) State Zip State Zip Employee's Name Address City ( ) Home Telephone -Social Security Number 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 M Sex F Fax Number TO EMPLOYEE (TO DEPENDENT(S) OR NEXT OF KIN IN CASE OF DEATH): This is to inform you that the claim for the injury on occupational disease as of death on , or , or is DENIED for the following reasons: / SIGNATURE EMPLOYER OR CARRIER/ADMINISTRATOR TITLE / DATE Employer/Insurance Carrier must provide a detailed statement of the grounds for denying compensability of the claim or liability for the claim where payments have previously been made without prejudice under N.C. Gen. Stat. § 97-18(d). Failure to specify a particular ground may preclude asserting certain defenses at a later date pursuant to N.C. Gen. Stat. § 97-18(f). Employee: If you disagree with this denial, you are entitled to request a hearing by submitting a Form 33. If you need assistance you may contact the Industrial Commission at the address below or telephone the Industrial Commission at (800) 688-8349. Employer: A copy of this form shall be sent to the employee and employee's attorney of record, if any, and all known health care providers which have submitted bills to the employer/carrier. The original of this form shall be sent to the Industrial Commission at the address below. EMAIL TO FORMS@IC.NC.GOV FORM 61 02/2016 PAGE 1 OF 1 CONTACT INFORMATION: FORM 61 NCIC-CLAIMS ADMINISTRATION TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com