North Carolina Industrial Commission IC File # Emp. Code # Carrier Code # Carrier File # Employer FEIN REPORT OF EMPLOYER OR CARRIER/ADMINISTRATOR OF COMPENSATION AND MEDICAL COMPENSATION PAID PURSUANT TO A COMPROMISE SETTLEMENT AGREEMENT The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act THIS FORM IS ONLY TO BE USED IN SETTLED CASES ( Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address City State Fax Number Zip City ) Telephone Number State Zip ( ) M Sex ( F / ) / ( ) ( ) Home Telephone Work Telephone Date of Birth XXX-XXLast 4 Digits of SSN Carrier's Telephone Number 1. 2. 3. Date of accident or disability from occupational disease ________________________________________. Salary was / was not continued. Total Dollar Amount Number of weeks temporary total _____ from ______________ , through ______________ $______________ _____ from ______________ , through ______________ $______________ 4. Number of weeks temporary partial _____ from ______________ , through ______________ $______________ _____ from ______________ , through ______________ $______________ 5. 6. 7. 8. 9. 10. Number of weeks permanent partial _____ from ______________ , through ______________ $______________ Disfigurement amount paid Loss of organ or body part benefits paid TOTAL OF LINES 3 THROUGH 7 Compromise Settlement Agreement amount Total Medical Paid $______________ $______________ $______________ $______________ $______________ NAME OF EMPLOYER OR CARRIER/ADMINISTRATOR SIGNATURE TITLE DATE This form must be filed with the Industrial Commission at the address below. FOR INDUSTRIAL COMMISSION USE ONLY Days Medical IC Code: ____________________ $____________________ ____________________ Compensation Paid $____________________ FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML FORM 28C 02/2017 PAGE 1 OF 1 CONTACT INFORMATION: FORM 28C NCIC-CLAIMS ADMINISTRATION TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com