Fill and Sign the Form 19 Compensation Claims Solutions

FORM 29 02/2017 P AGE 1 OF 1 FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP ://WWW .IC.NC .GOV /DOCFILING .HTML CONTACT INFORMATION : NCIC-C LAIMS ADMINISTRATION T ELEPHONE : (919) 807-2502 H ELPLINE : (800) 688-8349 W EBSITE : HTTP ://WWW .IC.NC .GOV F ORM 29 North Carolina Industrial Commission IC File # S UPPLEMENTAL R EPORT FOR F ATAL A CCIDENTS Emp. Code # (F ORM 19, EMPLOYER ’S REPORT OF EMPLOYEE ’S INJURY TO THE Carrier Code # INDUSTRIAL COMMISSION , MUST ALSO BE SUBMITTED IN EVERY CASE ) Employer FEIN The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence. Code numbers assigned to each employer and carrier should be inserted before mailing. ( ) Deceased 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 1. Date of accident: 2. Date of death: , 20 3. Dependents, or if employee left no dependents, next of kin: (Indicate which are non-resident aliens) Name Date of Birth Relationship Present Address a. b. c. d. e. f. 4. Immediate cause of death: 5. Amount of burial expenses authorized $ Signature of Employer or Carrier/Administrator Title Date