FORM 26D 09/2018 PAGE 1 OF 1 MAIL TO: 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/ FORM 26D North Carolina Industrial Commission IC File # A GREEMENT FOR PAYMENT OF UNPAID COMPENSATION Emp. Code # I N UNRELATED DEATH CASES (G.S. 247 97-37) Carrier Code # The Use of This Form Is Required Under the Provisions of the Workers' Compensation ActCarrier File # Employer FEIN ( ) Deceased Employee222s Name Employer's Name Telephone Number A ddress Employer222s Address City State Zip City State ZipInsurance Carrier ( ) ( ) Home Telephone Work TelephoneCarrier's Address City State Zip XXX-XX- M F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth Carrier's Telephone Number Fax Number WE, THE UNDERSIGNED, DO HEREBY AGREE AND STIPULATE AS FOLLOWS: 1. A ll parties hereto are subject to and bound by the provisions of the North Carolina Workers222 Compensation Act. 2. Deceased employee contracted an occupational disease or sustained an injury by accident arising out of and in the course of employment on (date of accident or occupational disease). 3. The accident or occupational disease resulted in the following injury and disability : Description of injury and permanent disability 4. The employee earned an average weekly wage of $ , which resulted in payment of compensation at the rate of $ per week for temporary total disability for weeks covering the period from to and for permanent partial disability fo r weeks, and is entitled to the unpaid balance of weeks of permanent partial disability compensation for . Rating of body part pursuant to G.S. 97-31 5. Employee died on , 20 , from causes unrelated to the occupational disease or injury by accident referenced in No. 2 above. 6. The following is/are the whole dependent(s), partial dependent(s), next of kin, or personal representative of the estate of deceased employee: 7. The parties agree to pay and receive the balance of the compensation at the rate of $ per week for a period of weeks beginning , 20. Signature of dependent, next of kin or personal representative Signature of Employer Title Signature of dependent, next of kin or personal representative Signature of Carrier/Administrator Title NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING AGREEMENT IS HEREBY APPROVED: Signature of claimant222s attorney CLAIMS EXAMINER DATE Attorney222s address ATTORNEY222S FEE APPROVED American LegalNet, Inc. www.FormsWorkFlow.com