Fill and Sign the North Carolina Accidents Form

I.C. FILE No.       CARRIER FILE No.       EMPLOYER CODE No.       CARRIER CODE No.       1. Name of employer       3. Date of accident       5. Name of employee       2. Address       4. Date of death       6. Address       a.       b.       C.       d.       e.       f.       g.       h.                                                                                                                                                           9. Did you authorize burial expenses?       If so, for what amount?       10. Name and address of undertaker       Name of Employer       Official Title       Date of this report             FORM.. 29-R-, 11/91 THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE WORKERS' COMPENSATION ACT NORTH CAROLINA INDUSTRIAL COMMISSION RALEIGH The I.C. File No. is the unique iden-tifier for this injury. It should be usedon all future correspondence.Code numbers assigned to eachemployer and carrier should be in-serted before mailing. SUPPLEMENTARY REPORT FOR FATAL ACCIDENTS (A first report of accident must also he made in every case) 7. Dependents: (If employee left no dependents, give name and address of next of kin.) Name Date of Birth Relationship Present Address Indicate which are non-resident aliens.8. Immediate cause of death Signed , . NOTE:- Every question must be answered. Report must be signed by, employer or his duly authorized agent. The Commission will not accept copies or reports signed by typewriter.