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GS-97 NC Industrial Forms

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North Carolina Industrial Commission

EMPLOYER'S ADMISSION OF EMPLOYEE'S RIGHT TO COMPENSATION (G.S. § 97-18(b))

The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act

IC File #

Emp. Code #

Carrier Code #

Carrier File #

Employer FEIN

Employee's Name

Employer's Name

() Telephone Number

Address

Employer's Address

City State Zip

City State Zip

Home Telephone

Work Telephone

Insurance Carrier

Policy Number

Last 4 Digits of SSN

Sex M F

Date of Birth

Carrier's Address

City State Zip

() Carrier's Telephone Number

Fax Number

TO DEFENDANTS: Describe with particularity the body part(s) or condition(s) for which you are admitting liability and compensability.

TO EMPLOYEE: Your employer admits your right to compensation for an

injury by accident on (date) (Specify body part(s) involved):

occupational disease on (date) (Specify condition(s) and body part(s) involved):

THE FOLLOWING ITEMS 1 THROUGH 4 ARE PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE 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 results in a weekly compensation rate of $

a. Temporary total compensation is being paid at the compensation rate above.

b. Temporary partial compensation is being 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

TITLE

DATE

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 record, if any, and the original provided to the Industrial Commission at the address below.

FORM 60

02/2017

PAGE 1 OF 1

FORM 60

FILE VIA ELECTRONIC DOCUMENT FILING PORTAL

HTTP://WWW.IC.NC.GOV/DOCFILING.HTML

CONTACT INFORMATION:

NCIC-CLAIMS ADMINISTRATION

TELEPHONE: (919) 807-2502

HELPLINE: (800) 688-8349

WEBSITE: HTTP://WWW.IC.NC.GOV

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What the GS-97 NC Industrial Forms Are and when they apply

The GS-97 NC Industrial Forms are standardized documents used in North Carolina to record industrial transactions, certifications, inspections, and related compliance data for facilities and contractors. They consolidate key project identifiers, scope descriptions, responsible parties, required safety or environmental attestations, and administrative details onto a uniform template that jurisdictions and contractors recognize. While formats vary by issuing agency, the GS-97 label denotes an industrial-class form used to document work authorizations, equipment certifications, site conditions, or material handling details needed for regulatory review, permitting, or internal records.

Why a correctly completed GS-97 NC Industrial Form matters

Completing the GS-97 NC Industrial Forms accurately reduces processing delays, supports regulatory compliance, and creates a durable record of industrial activity for audits or inspections. Proper completion helps avoid rework, potential fines, and interruptions to project timelines.

Why a correctly completed GS-97 NC Industrial Form matters

Typical users and signers of the GS-97 NC Industrial Forms

Each signatory should match the role named on the form and provide verifiable contact details to support attribution and follow-up.

  • Project managers and site supervisors responsible for submitting project details to regulatory or permitting offices.
  • Contractors and subcontractors certifying scope, materials, or compliance with safety and environmental conditions.
  • Quality control or compliance officers who verify inspections, maintenance, or corrective actions.

Primary responsibilities for signatories

Plant Manager

The Plant Manager typically certifies operational data and signs for company-level attestations. They confirm accuracy of submitted information and accept responsibility for compliance and corrective actions on behalf of the facility.

Certifying Engineer

A licensed engineer or qualified inspector provides technical attestations, signs inspection or test results, and confirms that equipment or procedures meet applicable standards before the form is filed.

Essential components of a professional GS-97 submission

A complete GS-97 NC Industrial Form combines administrative, technical, and compliance details so reviewers can assess scope and risk quickly. The following elements are commonly required or recommended.

Header Data

Facility name, physical address, project identifier, permit or contract number, and point of contact information for streamlined routing and record linkage.

Scope Description

A concise but specific description of work, materials, equipment, or processes addressed by the form, including start and end dates where applicable.

Compliance Statements

Checkboxes or attestations confirming adherence to safety, environmental, and operational standards; reference any applicable regulations or internal procedures.

Technical Findings

Inspection results, test data, or measurements presented in tabular or narrative form with units and sampling dates, plus the inspector's name and credential.

Signatures and Dates

Named signers, printed names, titles, signature blocks, and dates for each party required to execute or accept the record.

Attachments

Linked exhibits such as drawings, certificates, photographs, or lab reports that substantiate claims and provide evidentiary support for inspections.

Step-by-step: filling and submitting a GS-97 NC Industrial Form

Follow these sequential steps to complete, verify, and route the GS-97 form for processing and record retention.

  • 01
    Gather documents: Collect drawings, certificates, and test data for attachment.
  • 02
    Complete fields: Fill all required fields using specified formats.
  • 03
    Review and initial: Have technical lead verify measurements and attestations.
  • 04
    Sign and submit: Obtain required signatures, then route to the issuing office.

Typical GS-97 review and routing flow

A compact workflow helps ensure correct routing from preparer to final approver and archives the form with supporting evidence.

  • Preparer: Completes the form and attaches documentation.
  • Technical reviewer: Verifies data and signs technical sections.
  • Compliance officer: Checks regulatory attestations and countersigns.
  • Records archive: Stores the final copy with audit details.

Configuring a digital GS-97 workflow

Set these common workflow settings when moving the GS-97 to an electronic signing or routing platform.

Field Configuration
Signer order Sequential or parallel depending on organizational approval policies
Authentication Email link or multi-factor authentication for high-risk submissions
Attachments Require mandatory file types (PDF, DOCX) and size limits
Retention Automatic archive to records system with audit log

Technical options for digital completion and eSubmission

Confirm the platform can produce an audit trail, retain a tamper-evident copy, and allow export to your records repository for compliance and audits.

  • File formats: PDF, DOCX supported
  • Integrations: Connectors to NetSuite, Salesforce, Box
  • Authentication: Email, SMS, or advanced MFA

Common timing expectations and processing windows

Processing times and deadlines for GS-97 submissions differ by issuing agency and by the nature of the filing; allow additional time for technical review or corrections.

Initial submission window:

Submit according to contract or permit schedule; early submissions reduce backlog

Agency review period:

Allow 5–15 business days typical for non-technical checks

Technical review:

Inspection or technical validation may add 10–30 business days

Corrections period:

Responses to deficiency notices often expected within 10 business days

Final archiving:

Complete and archived after approvals; retained per records policy

Key milestones from creation to archival

A milestone view clarifies responsibilities and handoffs across the GS-97 lifecycle.

01

Form Preparation

Preparer compiles data and attachments for submission.

02

Internal Approval

Site or project approver reviews and signs the form.

03

Agency Review

Issuing agency or reviewer performs compliance checks.

04

Final Archive

Approved form is stored with audit details and attachments.

Common mistakes that lead to rejections or delays

  • Incomplete attachments: omitting required drawings or test reports forces resubmission and review delays.
  • Name mismatches: signer names that differ from official records can invalidate attestations and trigger identity checks.
  • Incorrect dates or formats: inconsistent use of date formats or missing effective dates complicates timeline reconciliation.
  • Insufficient technical detail: vague scope descriptions or missing measurement units require follow-up and technical clarifications.

Key data elements required on the GS-97

Facility ID: Permit or site number
Contact: Full name and phone
Address: Street, city, state, ZIP
Dates: Start and end dates
Inspector: Name and credential
Attachments: Reports and photos

Potential consequences for incorrect or late submissions

Filing Penalty: Late fees possible
Operational Risk: Work stoppage risk
Liability Exposure: Increased legal risk
Permit Delay: Project schedule impact
Audit Findings: Corrective actions required
Record Rejection: Form returned for rework

How the GS-97 compares to general industrial permit templates

This quick comparison shows typical GS-97 attributes vs. a generic industrial permit form used in other jurisdictions.

Criteria GS-97 NC Generic Industrial Form
Standardized fields varies
Attachment required varies
Notarization sometimes
State-specific clauses often

eSignature vendor pricing and capability snapshot relevant to GS-97 workflows

The table below lists starting prices and select capability indicators for signNow and common competitors; platform choice affects authentication, audit trails, and cost per user or per signature.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes (tiered) Varies by plan Varies by plan Varies by plan Varies by plan
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Varies by plan Varies by plan Varies by plan Varies by plan
Envelope Cap No cap 100 envelopes/user/year limit Varies Varies Varies

Frequently asked questions about completing and submitting GS-97 forms

Answers to common questions about formatting, signatures, attachments, and digital submission for the GS-97 NC Industrial Forms.


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