Fill and Sign the Report of Employer or Carrieradministrator of Form

FORM 28C 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 28C North Carolina Industrial Commission IC File # R EPORT OF E MPLOYER OR C ARRIER /A DMINISTRATOR OF Emp. Code # C OMPENSATION AND M EDICAL C OMPENSATION P AID Carrier Code # P URSUANT TO A C OMPROMISE SETTLEMENT A GREEMENT The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Carrier File # Employer FEIN T HIS F ORM IS O NLY TO BE USED IN S ETTLED C ASES ( ) 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 or disability from occupational disease ________________________________________. 2. Salary was / was not continued. Total Dollar Amount 3. Number of weeks temporary total ___ __ from _____________ _ , through ______________ $_____________ _ ____ _ from _____________ _ , through ______________ $_____________ _ 4. Number of weeks temporary partial ____ _ from _____________ _ , through ______________ $_____________ _ ____ _ from _____________ _ , through ______________ $_____________ _ 5. Number of weeks permanent partial ____ _ from _____________ _ , through ______________ $_____________ _ 6. Disfigurement amount paid $______________ 7. Loss of organ or body part benefits paid $______________ 8. TOTAL OF LINES 3 THROUGH 7 $______________ 9. Compromise Settlement Agreement amount $______________ Total Medical Paid $______________ 10. NAME OF EMPLOYER OR CARRIER /ADMINISTRATOR S IGNATURE T ITLE D ATE This form must be filed with the Industrial Commission at the address below. FOR INDUSTRIAL COMMISSION USE ONLY Days ____________________ Compensation Paid $____________________ Medical $____________________ IC Code: ____________________