Fill and Sign the Fillable Online Mipi Jukebox Registration Form Insound

FORM 33R 10/2017 P AGE 1 OF 2 ATTORNEYS/CARRIERS : F ILE VIA ELECTRONIC DOCUMENT FILING PORTAL : HTTP ://WWW .IC .NC .GOV /DOCFILING .HTML E MPLOYEE FILING OPTIONS : E- MAIL TO DOCKETS @IC.NC .GOV OR F AX TO (919) 715-0282 OR MAIL TO NCIC-D OCKET SECTION 1236 M AIL SERVICE CENTER R ALEIGH , NC 27699-1236 H ELPLINE : (800) 688-8349 W EBSITE : HTTP :/ /WWW .IC .NC .GOV F ORM 33R North Carolina Industrial Commission IC File # R ESPONSE TO REQUEST THAT CLAIM BE ASSIGNED FOR H EARING The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act ( ) Employee’s Name Employer's Name Telephone Number Address Employer’s Address City State Zip City State Zip Insurance Carrier ( ) ( ) Home Telephone Work TelephoneCarrier's Address City State Zip XXX-XX- ฀ M ฀ F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth Carrier's Telephone Number Fax Number In response to the Request for Hearin g filed we have been unable to a gree because (state reason with specificit y): PLAINTIFF/DEFENDANT AGREES TO THE FOLLOWING: Compensabilit y Denied Compensabilit y Admitted Sub ject to Act: Form 21 approved on: Emplo yment relationship: Form 60 approved on: Insurance covera ge: Temp. total paid from: Date of in jury: to Injury by acciden t Temp. partial paid from: Arisin g out of and in the course of emplo yment: to Perm. partial paid from: Occupational disease to Avera ge weekl y wa ge $ for % ppd of Part of bod y: Form 26 approved on: Other: __________________________ ____________ Form 24 approved on: Form 28B filed on: Other: Part of bod y: Cit y and count y wherein in jury occurred: Estimated len gth of hearin g: FORM 33R 10/2017 P AGE 2 OF 2 ATTORNEYS/CARRIERS : F ILE VIA ELECTRONIC DOCUMENT FILING PORTAL : HTTP ://WWW .IC .NC .GOV /DOCFILING .HTML E MPLOYEE FILING OPTIONS : E- MAIL TO DOCKETS @IC.NC .GOV OR F AX TO (919) 715-0282 OR MAIL TO NCIC-D OCKET SECTION 1236 M AIL SERVICE CENTER R ALEIGH , NC 27699-1236 H ELPLINE : (800) 688-8349 W EBSITE : HTTP :/ /WWW .IC .NC .GOV F ORM 33R Below is a list of names and addresses of all witnesses, including doctors, whose testimony is to be taken by the undersigned. NAME ADDRESS When a date of hearing is set, I respectfully request the Commission to send me signed subpoenas for my witnesses. When I receive these subpoenas, I will serve them pursuant to the inst ructions on Page 2 of the Industrial Commission Form 36. (Signature) Title (Address: street and number, city, state and zip) (Email Address) (Date) Note: The original of this form must be sent to the I ndustrial Commission at the address below or by e-mail to dockets@ic.nc.gov. A copy of the form must be sent to opposing parties. CERTIFICATE OF SERVICE I hereby certify that on _________________________, I served a co py of this Form 33R Response to Request That Claim Be Assigned for Hearing, together with all supporting documents, on the following party(ies) by way of ____________________________________________________________. (U.S. Mail, special delivery mail, e-mail, fax, hand delivery, etc.) [Note: List name and address of each attorney or party served. Attach a separate sheet if necessary.] ___________________________________________________________________________________________________________ Signature Printed Name Date