Fill and Sign the Form 18 Nc Industrial Commission Ncgov

FORM 30A 02/2017 P AGE 1 OF 1 F ILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP ://WWW .IC .NC .GOV /DOCFILING .HTML CONTACT INFORMATION : NCIC-CLAIMS ADMINISTRATION T ELEPHONE : (919) 807-2502 H ELPLINE : (800) 688-8349 W EBSITE : HTTP ://WWW .IC .NC .GOV F ORM 30A North Carolina Industrial Commission IC File # N OTICE OF AWARD Emp. Code # Employer FEIN Carrier File # The Use of This Form Is Required Under the Provisions of the Workers’ Compensation Act. Carrier Code # ( ) Employee’s Name Employer's Name Telephone Number Address Employer’s Address City State Zip City State Zip Insurance Carrier ( ) ( ) Home Telephone Work Telephone Carrier's Address City State Zip XXX-XX- M F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth Carrier's Telephone Number Fax Number The above parties have previously submitted an agreement for compensation for disability or death on Form . The Commission entered an award in the case upon receipt of the agreement. The Commission has now been informed that . Therefore, the original award is amended as follows: As above mentioned, said Agreement is hereby approved. This is a formal award of the Industrial Commission. Any interested party may give notice of appeal therefrom within fifteen (15) days or receipt of this award. SIGNATURE TITLE DATE