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Itemized Statement of Charges for Travel North Carolina  Form

Itemized Statement of Charges for Travel North Carolina Form

Use a form 28c template to make your document workflow more streamlined.

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...
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  3. Use the Cross or Check marks in the top toolbar to select your answers in the list boxes.
  4. Utilize the Circle icon for other Yes/No questions.
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  6. Insert the current Date with the corresponding icon.
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