The North Carolina 62 form is a crucial document utilized in the context of workers' compensation, specifically for notifying the Industrial Commission about the reinstatement or modification of an employee's compensation. This form is governed by the provisions outlined in the Workers' Compensation Act, ensuring that both employers and employees are informed about changes in compensation status. Understanding the details and requirements of this form is essential for compliance and effective communication between all parties involved.
The North Carolina 62 form plays a crucial role in the state's workers' compensation process. This form is used to notify the North Carolina Industrial Commission about the reinstatement or modification of compensation for injured employees. It is required under specific provisions of the Workers' Compensation Act, specifically G.S. §97-32.1 or §97-18(b). Essential details such as the employee's name, employer's information, and the insurance carrier's policy number are included. The form also specifies the date of injury and the amount of compensation being reinstated or modified. It outlines the employee's average weekly wage, which determines the compensation rate. Depending on the circumstances, different types of compensation may be indicated, such as temporary total or partial compensation. Once completed, the original form must be sent to the Industrial Commission, while copies are provided to the employee and their attorney, if applicable. This process ensures that all parties are informed and that compensation adjustments are properly documented.
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NORTH CAROLINA INDUSTRIAL COMMISSION
IC File #
NOTICE OF REINSTATEMENT OR MODIFICATION OF
COMPENSATION (G.S. §97-32.1 OR §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
Date of Injury:
Compensation in the amount of $ .
per week was reinstated or modified on
pursuant to
N.C. Gen. Stat. § 97-32.1
or
N.C. Gen. Stat. § 97-18(b).
Give reason for reinstatement:
The employee's average weekly wage, 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:
SIGNATURE EMPLOYER OR CARRIER/ADMINISTRATOR
TITLE
DATE
Employer: The original of this form must be sent to the Industrial Commission at the address below. A copy shall be provided to the employee and the employee's attorney of record, if any.
MAIL TO: NCIC - CLAIMS SECTION
FORM 62
4335 MAIL SERVICE CENTER
RALEIGH, NC 27699-4335
10/2006
PAGE 1 OF 1
TELEPHONE: (919) 807-2502
HELPLINE: (800) 688-8349
WEBSITE: HTTP://WWW.IC.NC.GOV/
Here are key takeaways for filling out and using the North Carolina 62 form: