The North Carolina 60 form is a critical document used by employers to acknowledge an employee's right to compensation under the state's Workers' Compensation Act. This form serves as an official admission of liability for workplace injuries or occupational diseases, detailing essential information about the incident and the employee's compensation rights. Understanding the nuances of this form is essential for both employers and employees navigating the workers' compensation system in North Carolina.
The North Carolina 60 form plays a crucial role in the state's workers' compensation system, facilitating communication between employers, employees, and insurance carriers. This form is specifically designed for employers to formally admit an employee's right to compensation following an injury or occupational disease. It requires essential information, such as the employee's name, the employer's details, and the nature of the injury or condition. Notably, it outlines the specifics of the injury, including the date it occurred and the body parts affected. Employers must also provide information about the employee's average weekly wage, which is vital for determining compensation rates. Additionally, the form highlights the importance of timely filing, as failure to submit the necessary reports can lead to penalties. This document not only serves as a record of the employer's admission of liability but also ensures that employees are informed of their rights and the compensation process. Understanding the North Carolina 60 form is essential for both employers and employees navigating the complexities of workers' compensation claims.
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NORTH CAROLINA INDUSTRIAL COMMISSION
IC File #
EMPLOYER’S ADMISSION OF EMPLOYEE’S RIGHT TO
COMPENSATION (G.S. §97-18(B))
Emp. Code #
Carrier Code # Carrier File #
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
Employer FEIN
(
)
-
Employee’s Name
Employer’s Name
Telephone Number
Address
Employer’s Address
City
State
Zip
Insurance Carrier
Policy Number
( )
Home Telephone
Work Telephone
Carrier’s Address
M
F
/
Social Security Number
Sex
Date of Birth
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.
SELF-INSURED EMPLOYER OR CARRIER MAIL TO:
FORM 60
NCIC - CLAIMS ADMINISTRATION
8/1/08
4335 MAIL SERVICE CENTER
PAGE 1 OF 1
RALEIGH, NORTH CAROLINA 27699-4335
MAIN TELEPHONE: (919) 807-2500
HELPLINE: (800) 688-8349
WEBSITE: HTTP://WWW.IC.NC.GOV/