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Itemized Statement of Charges for Travel North Carolina Form
Code The Use of This Form Is Required Under the Provisions of the Workers Compensation Act Carrier File THIS FORM IS ONLY TO BE USED IN SETTLED CASES Employee s Name Address Employer s Address City State Home Telephone Zip Work Telephone Last 4 Digits of SSN / Sex Telephone Number Insurance Carrier M F XXX-XX- Carrier s Address Date of Birth Carrier s Telephone Number Fax Number Date of accident or disability from occupational disease. Salary was / was not continued. Number of weeks...Show details
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