Get NC Form 61 2017-2023
Equired Under the Provisions of the Workers' Compensation Act Employer FEIN ( ) Telephone Number Employee’s Name Employer’s Name Address Employer’s Address City Insurance Carrier Policy Number Carrier’s Address ( ) - City ( ) Carrier’s Telephone Number Fax Number City State ( ) Home Telephone XXX-XX- M Last 4 Digits of SSN Sex F Zip ( ) Work Telephone / / Date of Birth State Zip State Zip - Date of Injury: TO EMPLOYEE (TO DEPENDENT(S) OR NEXT OF KIN IN CASE .
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