Free Form 87S - North Carolina

North Carolina Industrial Commission

IC File #

STATEMENT OF ACCRUED ARREARAGES G.S. 97-87(C )(1)
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Employer FEIN
The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence..

I.C. No. ____________; _________________, Employee, Plaintiff; v. _________________________, Employer; and __________________________ Carrier; Defendants. PURSUANT TO N.C. Gen. Stat. § 97-87, claimant hereby seeks the issuance of a Certificate of Accrued Arrearages and states as follows: 1. Claimant is entitled to monetary benefits from defendant(s) pursuant to:
Please check appropriate box and provide filed date in blank.

Opinion & Award Form 21 Form 26 Other Order

_________________ _________________ _________________
Specify Order and Filed Date

Form 60 Form 62 Form 63

_________________ _________________ _________________

_________________________________________________________

2. The following sums remain unpaid. Explain the basis for each sum, e.g. # weeks x comp rate after a specific date. An accrued arrearage requires that the time for making payment has expired. $ __________principal
Explain Calculation

. .
Explain Calculation

$ __________interest $ __________costs, etc.
Explain Calculation

.

3. As of _____________________ the total accrued arrearage was $_________________________.
Date of Application

The undersigned hereby certifies that the above order or award is in full force and effect, that the time for making payment has expired and claimant is entitled to the sum stated in paragraph 3.
_______________________________________________________ Signature: Claimant Attorney _______________________________________________________ Address _____________________________________________________ Telephone

FORM 87S 7/08 PAGE 1 OF 2

FORM 87S

MAIL TO: THE FULL COMMISSION NORTH CAROLINA INDUSTRIAL COMMISSION 4336 MAIL SERVICE CENTER RALEIGH, NC 27699-4336

CERTIFICATE OF SERVICE This is to certify that I have this day served a copy of the foregoing Statement of Accrued Arrearages upon the below listed persons by depositing a copy of same in the United States mail, postage prepaid, addressed as follows:

This the ____ day of _______________, 20__.
___________________________________________ Signature ___________________________________________ Address ___________________________________________ Telephone

Note: 97-87(c )(1) provides, in pertinent part: The claimant ... shall serve a copy [of the Statement of Accrued Arrearages] on all parties against whom judgment is sought and their attorney of record. Note: 97-87(c ) provides: 1. Any party against whom judgment is sought may, within 15 days of the date of service of a Statement of Accrued Arrearages, file with the Commission proof of any payments that have been made or other responsive pleadings. 2. If no proof or other responsive pleading is filed within 15 days of the date of service of the Statement, the Commission shall immediately issue a Certificate of Accrued Arrearages.

FORM 87S 7/08 PAGE 2 OF 2

FORM 87S

MAIL TO: THE FULL COMMISSION NORTH CAROLINA INDUSTRIAL COMMISSION 4336 MAIL SERVICE CENTER RALEIGH, NC 27699-4336