North Carolina Industrial Commission IC File # Emp. Code # Carrier Code # Employer FEIN AWARD APPROVING AGREEMENT FOR COMPENSATION FOR DEATH The Use of This Form Is NOT Required Under the Provisions of the Workers' Compensation Act ( Deceased Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address City City ) - Telephone Number State Zip ( - ) - M Sex ( F ) / State Zip Home Telephone Social Security Number Work Telephone / ( ) - ( ) - Date of Birth Carrier's Telephone Number Fax Number Employer or carrier shall complete and submit to the Industrial Commission for approval this form or a document containing all pertinent information The parties now have executed and submitted for approval a Form 30 Agreement for Compensation for Death, which is incorporated herein by reference. The Commission hereby approves said Agreement and directs payment of compensation to the person(s) and at the rate(s) as follows: Person(s) Receiving Compensation Compensation Rate Time Period or Lump Sum In addition, the employer and its insurance carrier, if any, shall pay burial expenses not exceeding $10,000.00 to the person or persons entitled for deaths occurring on or after October 1, 2001. The employer and its insurance carrier, if any, shall pay all medical, hospital, nursing and other treatment expenses incurred by or on behalf of deceased employee as a result of the injury causing death when bills have been submitted to and approved through the procedure adopted by the Industrial Commission. An attorney's fee of $ . is approved for counsel for claimant(s). This amount shall be deducted from the amount claimant(s) is/are to receive, and paid directly to counsel. Employer and its insurance carrier, if any, shall pay the costs of this action. This is an award of the Industrial Commission and any interested party may give notice of appeal within the time and in the manner provided by law. NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING AGREEMENT IS HEREBY APPROVED: CLAIMS EXAMINER / / DATE EMAIL TO FORMS@IC.NC.GOV FORM 30D 02/2016 PAGE 1 OF 1 CONTACT INFORMATION: FORM 30D NCIC-CLAIMS ADMINISTRATION TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com