Free Form 33R - North Carolina


File Size: 27.6 kB
Pages: 2
File Format: PDF
State: North Carolina
Category: Workers Compensation
Author: Mcdowelr
Word Count: 393 Words, 2,401 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ic.nc.gov/ncic/pages/form33r.pdf

Download Form 33R ( 27.6 kB)


Preview Form 33R
North Carolina Industrial Commission
IC File #

RESPONSE TO REQUEST THAT CLAIM BE ASSIGNED FOR HEARING
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

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

(
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

In response to the Request for Hearing filed we have been unable to agree to the benefits claimed because (state reason with specificity):

DEFENDANT AGREES TO THE FOLLOWING:

Compensability Denied Subject to Act: Employment relationship: Insurance coverage: Date of injury: Injury by accident Arising out of and in the course of employment: Occupational disease Average weekly wage $ Other:

Compensability Admitted Form 21 approved on: Form 60 approved on: Temp. total paid from: to Temp. partial paid from: to Perm. partial paid from: to for % ppd of Form 26 approved on: Form 24 approved on: Form 28B filed on: Other: Part of body:

City and county wherein injury occurred: Estimated length of hearing:

MAIL TO:
FORM 33R 2/01 PAGE 1 OF 2

FORM 33R

NCIC ­ DOCKETS SECTION 4336MAIL SERVICE CENTER RALEIGH, NC 27699-4336 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/

Below is a list of names and addresses of all witnesses, including doctors, whose testimony is to be taken by the undersigned. Doctors outside the county of hearing are not required to attend this hearing. NAME ADDRESS

When a date of hearing is set, I respectfully request the Commission to send me signed subpoenas for my witnesses. When I receive these subpoenas, I will deliver them to the Sheriff of the county or counties in which each witness resides so that the subpoenas may be served.

(Signature)

Title

(Address: street and number, city, state and zip)

(Date)

Note: A copy of this form must be sent to opposing parties. The original of this form must be sent to the Industrial Commission at the address below:

MAIL TO:
FORM 33R 2/01 PAGE 2 OF 2

FORM 33R

NCIC ­ DOCKETS SECTION 4336MAIL SERVICE CENTER RALEIGH, NC 27699-4336 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/