North Carolina Industrial Commission
IC File #
NOTICE OF REINSTATEMENT OR MODIFICATION OF COMPENSATION (G.S. §97-32.1 OR §97-18(b))
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 ( ) Home Telephone - Social Security Number Date of Injury: State ( ) Work Telephone / / Date of Birth Zip
Employer's Name Employer's Address Insurance Carrier Carrier's Address ( ) Carrier's Telephone Number City
( ) Telephone Number State Zip
Policy Number City ( ) State Zip
M Sex
F
Fax Number
. Compensation in the amount of $ pursuant to
per week was reinstated or modified on 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:
FORM 62 10/2006 PAGE 1 OF 1
FORM 62
NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH, NC 27699-4335 TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/