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Get Nc Ic Form 60

SELF-INSURED EMPLOYER OR CARRIER MAIL TO FORM 60 8/1/08 PAGE 1 OF 1 NCIC - CLAIMS ADMINISTRATION 4335 MAIL SERVICE CENTER RALEIGH NORTH CAROLINA 27699-4335 MAIN TELEPHONE 919 807-2500 HELPLINE 800 688-8349 WEBSITE HTTP //WWW.IC. 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 Address Employer s Address City Insurance Carrier - Policy Number State Home Telephone Zip M Social Security Number F Sex / Work Telephone Telephone Number Carrier s Address 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 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 The employee was paid for the entire day of injury. 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* 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. 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 Address Employer s Address City Insurance Carrier - Policy Number State Home Telephone Zip M Social Security Number F Sex / Work Telephone Telephone Number Carrier s Address 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 THE FOLLOWING ITEMS 1 THROUGH 4 ARE PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE AN AGREEMENT 1.

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