Free Form 28C - North Carolina

North Carolina Industrial Commission

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

REPORT OF EMPLOYER OR CARRIER/ADMINISTRATOR OF COMPENSATION AND MEDICAL COMPENSATION PAID PURSUANT TO A COMPROMISE SETTLEMENT AGREEMENT
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

THIS FORM IS ONLY TO BE USED IN SETTLED CASES
(
Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address City State Fax Number Zip City

)
Telephone Number State Zip

(

) M F

( /

) / ( ) ( )

Home Telephone Social Security Number Sex

Work Telephone Date of Birth

Carrier's Telephone Number

1. 2. 3.

Date of accident or disability from occupational disease ________________________________________. Salary was / was not continued. Total Dollar Amount

Number of weeks temporary total

_____ from ______________ , through ______________ $______________ _____ from ______________ , through ______________ $______________

4.

Number of weeks temporary partial _____ from ______________ , through ______________ $______________ _____ from ______________ , through ______________ $______________

5. 6. 7. 8. 9. 10.

Number of weeks permanent partial _____ from ______________ , through ______________ $______________ Disfigurement amount paid Loss of organ or body part benefits paid TOTAL OF LINES 3 THROUGH 7 Compromise Settlement Agreement amount Total Medical Paid $______________ $______________ $______________ $______________ $______________

NAME OF EMPLOYER OR CARRIER/ADMINISTRATOR

SIGNATURE

TITLE

DATE

This form must be filed with the Industrial Commission at the address below.
FOR INDUSTRIAL COMMISSION USE ONLY Days Medical IC Code: ____________________ $____________________ ____________________ Compensation Paid $____________________

FORM 28C 11/2003 PAGE 1 OF 1

MAIL TO:

NCIC - STATISTICS SECTION 4334 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4334

FORM 28C

MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/