North Carolina Industrial Commission IC File # NOTICE OF AWARD Emp. Code # Employer FEIN Carrier File # The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act. Carrier Code # ( Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address ) Telephone Number City State Zip ( ) M Sex ( F / ) City State Fax Number Zip Home Telephone Work Telephone XXX-XXLast 4 Digits of SSN / ( ) ( ) Date of Birth Carrier's Telephone Number The above parties have previously submitted an agreement for compensation for disability or death on Form . The Commission entered an award in the case upon receipt of the agreement. The Commission has now been informed that . Therefore, the original award is amended as follows: As above mentioned, said Agreement is hereby approved. This is a formal award of the Industrial Commission. Any interested party may give notice of appeal therefrom within fifteen (15) days or receipt of this award. SIGNATURE TITLE DATE FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML FORM 30A 02/2017 PAGE 1 OF 1 FORM 30A CONTACT INFORMATION: NCIC-CLAIMS ADMINISTRATION TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com