North Carolina Industrial Commission IC File # EMPLOYER'S ADMISSION OF EMPLOYEE'S RIGHT TO COMPENSATION (G.S. § 97-18(b)) The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Emp. Code # Carrier Code # Carrier File # Employer FEIN ( Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address City Policy Number 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 TO DEFENDANTS: Describe with particularity the body part(s) or condition(s) for which you are admitting liability and compensability. TO EMPLOYEE: Your employer admits your right to compensation for an injury by accident on / / (date) (Specify body part(s) involved): occupational disease on / / (date) (Specify condition(s) and body part(s) involved): THE FOLLOWING ITEMS 1 THROUGH 4 ARE PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE AN AGREEMENT: 1. The description of the injury or occupational disease, including body parts involved is: 2. 3. The employee was paid for the entire day of injury. Yes No , which results The employee's average weekly wage, subject to verification, including overtime and all allowances, was $ in a weekly compensation rate of $ . a. Temporary total compensation is being paid at the compensation rate above. b. c. Temporary partial compensation is being paid in the amount of $ Other: / / (date), and compensation commenced on / / . 4. The disability resulting from the injury began on (date). / SIGNATURE OF EMPLOYER OR CARRIER/ADMINISTRATOR TITLE / DATE EMPLOYER: Failure to file Form 28B, Report of Compensation and Medical Compensation Paid, within 16 days after last payment pursuant to an agreement or award subjects employer or carrier/administrator to a penalty pursuant to N.C. Gen. Stat. § 97-18(h). Form 30 must be used for compensable injuries resulting in death. A copy of this Form 60 shall be provided to the employee and the employee's attorney of record, if any, and the original provided to the Industrial Commission at the address below. EMAIL TO FORMS@IC.NC.GOV FORM 60 02/2016 PAGE 1 OF 1 CONTACT INFORMATION: FORM 60 NCIC-CLAIMS ADMINISTRATION TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com