North Carolina Industrial Commission IC File # AGREEMENT FOR COMPENSATION FOR DEATH The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Emp. Code # Carrier Code # Employer FEIN ( Deceased 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 We, the dependent(s) or next of kin listed below and the employer and carrier/administrator hereby stipulate to the following facts as to the death of the deceased employee: 1. The employer and the deceased employee were bound by the provisions of the N.C. Workers' Compensation Act; 2. The deceased employee sustained a compensable injury by accident (or occupational disease) on that arose out of and in the course of his employment and resulted in his death on 3. The average weekly wage of deceased employee was $ , , . . , , and the weekly compensation rate is $ 4. The parties hereto have provided the Industrial Commission with the names and addresses of all known persons wholly or partially dependent for support upon the earnings of the deceased employee at the time of the accident, or the next of kin who might be entitled to compensation if there are no whole or partial dependents. 5. The following are the only persons entitled to receive compensation as a result of the death of employee: Indicate whole or partial dependent or next of kin Name Address Date of Birth Age Relationship (IF ADDITIONAL SPACE NEEDED USE REVERSE SIDE) 6. Based upon the above stipulated facts, the employer and its carrier or third party administrator, agree to pay and the dependents, or next of kin agree to accept compensation based upon a weekly rate of $ payable as follows: (Check all that apply) if widow/widower only, for 500 weeks if widow/widower and minor child(ren), in equal shares for 500 weeks; however, minor child(ren) shall continue to receive compensation if they have not yet reached age 18 within the 500 week period if minor child(ren) only, in equal shares for 500 weeks or until they reach age 18, whichever is longer If whole dependent(s) other than widow/widower and/or child(ren), for 500 weeks if partial dependent(s) only, in the weekly amount of $ (compensation rate multiplied by the percentage of support provided by deceased) for 500 weeks EMAIL TO FORMS@IC.NC.GOV FORM 30 02/2016 PAGE 1 OF 2 CONTACT INFORMATION: FORM 30 NCIC-CLAIMS ADMINISTRATION TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com if next of kin, for 500 weeks payable in a lump sum commuted to present value in equal shares 7. The parties agree that the employee's surviving widow/widower was able or was unable to support herself/himself because of physical or mental disability as of the date of death of the employee, and will or will not continue to receive additional weekly benefits during his/her lifetime or until remarriage. 8. The employer and its carrier agree to pay burial expenses not exceeding $10,000.00 for deaths on or after October 1, 2001, and medical expenses in accordance with Commission procedure. 9. Compensation for death to be paid under this agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Amount due for expense of burial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Total amount to be paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10. The date of this agreement is , 20 . Signature of Dependent or Next of Kin Signature of Employer Title Signature of Dependent or Next of Kin Signature of Carrier/Administrator Signature of Dependent or Next of Kin Title Signature of Dependent or Next of Kin Signature of Plaintiff's Attorney NOTICE TO EMPLOYER OR CARRIER: A completed Form 30D Award Approving Agreement for Compensation for Death or a document containing all pertinent information MUST be submitted to the Industrial Commission along with this Form 30 Agreement for Compensation for Death. In addition, the following documents, if appropriate, should be attached to this Form: (1) death certificate; (2) marriage certificate; (3) divorce decree; (4) birth certificate, if minor; (5) Form 42 Application for Appointment of Guardian Ad Litem; and (6) Form 29 Supplemental Report for Fatal Accidents. MAIL TO: FORM 30 05/2012 PAGE 2 OF 2 FORM 30 NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH, NC 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/ American LegalNet, Inc. www.FormsWorkFlow.com