FORM 87C 10/2017 PAGE 1 OF 1 MAIL TO: FORM 87C THE FULL COMMISSION NORTH CAROLINA INDUSTRIAL COMMISSION 1236 MAIL SERVICE CENTER RALEIGH, NC 27699-1236 North Carolina Industrial Commission IC File # CERTIFICATE OF ACCRUED ARREARAGES Emp. Code # OR CERTIFIED ACCOUNTING OF AWARD Carrier Code # G.S. 97-87 Employer FEIN The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is tobe referenced in all future correspondence.. The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act I.C. No. ; , Employee, Plaintiff; v. , Employer; and Carrier; Defendants. FILED: The undersigned, upon application of claimant and pursuant to N.C. Gen. Stat. 247 97-87, enters a Certificate of Accrued Arrearages or Certified Accounting of an Award of the Commission as follows: 1. Provide the names and addresses of plaintiff, liable defendant-employer (and 3rd party administrator if applicable) and liable defendant-carrier. Claimant E m p lo y e r -Defendan t Name Address City, State, Zip Code Carrier-Defendant or 3rd Part y Administrato r Name Address City, State, Zip Code Name Address City, State, Zip Code 2. The sum of all principal amounts that have accrued and remain unpaid since the date of the award or since the date of the most recent prior Certificate of Accrued Arrearages is: $ . 3. The total of any interest that has accrued and remains unpaid since the date of the award or since the date of the most recent prior Certificate of Accrued Arrearages is: $ . 4. Costs, penalties, or monetary sanctions previously awarded are: $ . 5. The total sum remaining unpaid as of is $ . Date of Application The above named defendant(s) is/are jointly and severally liable and judgment shall be entered against all defendants. The undersigned hereby certifies that the information contained herein is a true accounting of the accrued arrearages due claimant pursuant to an Award of the Commission in this claim. This the day of , 20 . COMMISSIONER American LegalNet, Inc. www.FormsWorkFlow.com