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Get NC Form 28U 2017-2023

EIN The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act ( Employee’s Name Employer's Name Address Employer’s Address City ( State ) ( Home Telephone Last 4 Digits of SSN / Sex Telephone Number City State Zip City State Zip Insurance Carrier ) Work Telephone M F XXX-XX- Zip ) Carrier's Address ( / Date of Birth ) ( Carrier's Telephone Number ) Fax Number SECTION A. EMPLOYEE: COMPLETE AND MAIL TO EMPLOYER AND CARRIER/ADMIN.

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