Free Form 26D - North Carolina


File Size: 27.9 kB
Pages: 1
File Format: PDF
State: North Carolina
Category: Workers Compensation
Author: Mcdowelr
Word Count: 379 Words, 2,472 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ic.nc.gov/ncic/pages/form26d.pdf

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Preview Form 26D
North Carolina Industrial Commission
IC File #

AGREEMENT FOR PAYMENT OF UNPAID COMPENSATION IN UNRELATED DEATH CASES (G.S. 97- 37)
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Carrier File # Employer FEIN

(
Deceased Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address

)
Telephone Number City State Zip

(

) M F

( /

)
City State Fax Number Zip

Home Telephone Social Security Number Sex

Work Telephone

/

(

)

(

)

Date of Birth

Carrier's Telephone Number

WE, THE UNDERSIGNED, DO HEREBY AGREE AND STIPULATE AS FOLLOWS:
1. All parties hereto are subject to and bound by the provisions of the North Carolina Workers' Compensation Act. 2. Deceased employee contracted an occupational disease or sustained an injury by accident arising out of and in the course of employment on (date of accident or occupational disease). 3. The accident or occupational disease resulted in the following injury and disability :
Description of injury and permanent disability

4. The employee earned an average weekly wage of $ $ per week for temporary total disability for and for permanent partial disability for permanent partial disability compensation for

, which resulted in payment of compensation at the rate of weeks covering the period from weeks, and is entitled to the unpaid balance of
Rating of body part pursuant to G.S. 97-31

to weeks of .

5. Employee died on by accident referenced in No. 2 above. 6. The following is/are the deceased employee: whole dependent(s),

, 20

, from causes unrelated to the occupational disease or injury next of kin, or personal representative of the estate of per week for a

partial dependent(s),

7. The parties agree to pay and receive the balance of the compensation at the rate of $ period of weeks beginning , 20 .

Signature of dependent, next of kin or personal representative Signature of dependent, next of kin or personal representative

Signature of Employer Signature of Carrier/Administrator

Title Title

NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING AGREEMENT IS HEREBY APPROVED: Signature of claimant's attorney CLAIMS EXAMINER Attorney's address ATTORNEY'S FEE APPROVED DATE

MAIL TO:
FORM 26D 2/01 PAGE 1 OF 1

FORM 26D

NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH, NC 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/