North Carolina Industrial Commission IC File # SUPPLEMENTAL REPORT FOR FATAL ACCIDENTS (FORM 19, EMPLOYER'S REPORT OF EMPLOYEE'S INJURY TO THE INDUSTRIAL COMMISSION, MUST ALSO BE SUBMITTED IN EVERY CASE) The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Emp. Code # Carrier Code # Employer FEIN The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence. Code numbers assigned to each employer and carrier should be inserted before mailing. ( Deceased 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 1. Date of accident: 2. Date of death: , 20 3. Dependents, or if employee left no dependents, next of kin: (Indicate which are non-resident aliens) Name a. b. c. d. e. f. Date of Birth Relationship Present Address 4. Immediate cause of death: 5. Amount of burial expenses authorized $ Signature of Employer or Carrier/Administrator Title Date FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML FORM 29 02/2017 PAGE 1 OF 1 FORM 29 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