Employers Admission Of Employees Right To Compensation
Employers Admission Of Employees Right To Compensation Form. This is a North Carolina form and can be use in Workers Comp.
Tags: Employers Admission Of Employees Right To Compensation, 60, North Carolina Workers Comp,
North Carolina Industrial Commission IC File # EMPLOYER’S ADMISSION OF EMPLOYEE’S RIGHT TO COMPENSATION (G.S. §97-18(b)) Emp. Code # Carrier Code # Carrier File # The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Employer FEIN ( ) Employee’s Name Employer’s Name Address Employer’s Address City Insurance Carrier Policy Number Carrier’s Address City ( ( - City ( ) State - ( Home Telephone - Zip ) M Social Security Number F Sex / State Zip State Zip - Work Telephone - Telephone Number / 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 / / occupational disease on / (date) (Specify body part(s) involved): / (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. The employee was paid for the entire day of injury. 3. 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. Yes No b. c. 4. Temporary partial compensation is being paid in the amount of $ , which results . Other: The disability resulting from the injury began on / / (date), and compensation commenced 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. SELF-INSURED EMPLOYER OR CARRIER MAIL TO: FORM 60 8/1/08 PAGE 1 OF 1 NCIC - CLAIMS ADMINISTRATION 4335 MAIL SERVICE CENTER FORM 60 RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/ American LegalNet, Inc. www.FormsWorkflow.com