Fill and Sign the Gs97 18c and Gs97 18d Nc Industrial Form

FORM 60 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 60 North Carolina Industrial Commission IC File # E MPLOYER ’S A DMISSION OF EMPLOYEE ’S R IGHT TO Emp. Code # COMPENSATION (G.S. § 97-18(b)) Carrier Code # The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Carrier File # Employer FEIN ( ) - Employee’s Name Employer’s Name Telephone Number Address Employer’s Address City State Zip City State Zip Insurance Carrier Policy Number ( ) - ( ) - 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 T O DEFENDANTS : Describe with particularity the body part(s) or condition(s) for which you are admitting liability and compensability. T O EMPLOYEE : Your employer admits your right to compensation for an injury by accident on / / (date) (Specify body part(s) involved): occupational disease on / / (date) (Specif y condition(s) and body part(s) involved): THE FOLLOWING ITEMS 1 T HROUGH 4 ARE PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND DO NOT C ONSTITUTE AN AGREEMENT : 1. The description of the injury or occupational disease, including body parts involved is: 2. The employee was paid for the entire day of injury. Yes No 3. The employee's average weekly wage, subject to verification, including overtime and all allowances, was $ , which result s in a weekly compensation rate of $ . a. Temporary total compensation is being paid at the compensation rate above. b. Temporary partial compensation is be ing paid in the amount of $ . c. Other: 4. The disability resulting from the injury began on / / (date), and compensation commenced on / / (date). / / SIGNATURE OF EMPLOYER OR CARRIER /ADMINISTRATOR TITLEDATE EMPLOYER : Failure to file Form 28B, Report of Compensation and Medical Compensation Paid, within 16 days after last payment pursuant to an agreement or award subjects employer or carrier/administrator to a penalty pursuant to N.C. Gen. Stat. § 97-18(h). Form 30 must be used for compensable injuries resulting in death. A copy of this Form 60 shall be provided to the employee and the employee's attorney of r ecord, if any, and the original provided to the Industrial Commission at the address below.