Fill and Sign the Nec Sv8100 Sv8300 Sv8100 California Telephony Inc Form

AWARD APPROVING AGREEMENT FOR COMPENSATIONFOR DEATH Employer or carrier shall complete and submit to the Industrial Commission for approval this form or a document containing all pertinent information The parties now have executed and submitted for approval a Form 30 Agreement for Compensation for Death, which is incorporated herein by reference. The Commission hereby approves said Agreement and directs payment of compensation to the person(s) and at the rate(s) as follows- Time Period or Lump Sum Person(s) Receiving Compensation Compensation Rate In addition, the employer and its insurance carrier, if any, shall pay funeral expenses not to exceed $3500.00 to the person or persons entitled for deaths on or after October 1, 2001. The employer and its insurance carrier, if any, shall pay all medical, hospital, nursing and other treatment expenses incurred by or on behalf of deceased employee as a result of the injury causing death when bills have been submitted to and approved through the procedure adopted by the Industrial Commission. is approved for counsel for claimant(s). This amount shall be deducted from the amount An attorney's tee of $ claimant(s) is/are to receive, and paid directly to counsel. Employer and its insurance carrier, if any, shall pay the costs of this action. This is an award of the Industrial Commission and any interested party may give notice of appeal within the time and in the manner provided by law. NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING AGREEMENT IS HEREBY APPROVED: CLAIMS EXAMINER DATE NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER MAIL TO: FORM 30D RALEIGH, NC 27699-4335 11/01 FORM 30D MAIN TELEPHONE: (919) 807-2500 OMBUDSMAN: (800) 688-8349 PAGE 1 OF 1 North Carolina Industrial Commission IC File # Carrier Code # Employer FEIN The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Telephone Number Employer's Name Employee s Name City Zip State Employer's Address Address Insurance Carrier Zip Policy Number State City Carrier's Address City Zip State Work Telephone Home Telephone M F Carrier's Telephone Number Date of Birth Fax Number Sex Social Security Number Emp. Code #