Free Form 30D - North Carolina

North Carolina Industrial Commission

IC File # Emp. Code # Carrier Code #

AWARD APPROVING AGREEMENT FOR COMPENSATION FOR DEATH

The Use Of This Form Is NOT Required Under The Provisions of The Workers' Compensation Act Employer FEIN (
Deceased Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address City State Zip City

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Telephone Number State Zip

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Sex

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Home Telephone Social Security Number

Work Telephone Date of Birth

Carrier's Telephone Number

Fax Number

Employer or carrier shall complete and submit to the Industrial Commission for approval this form or a document containing all pertinent information
The parties now have executed and submitted for approval a Form 30 Agreement for Compensation for Death, which is incorporated herein by reference. The Commission hereby approves said Agreement and directs payment of compensation to the person(s) and at the rate(s) as follows: Person(s) Receiving Compensation Compensation Rate Time Period or Lump Sum

In addition, the employer and its insurance carrier, if any, shall pay burial expenses not exceeding $3,500.00 to the person or persons entitled for deaths occurring on or after October 1, 2001. The employer and its insurance carrier, if any, shall pay all medical, hospital, nursing and other treatment expenses incurred by or on behalf of deceased employee as a result of the injury causing death when bills have been submitted to and approved through the procedure adopted by the Industrial Commission. is approved for counsel for claimant(s). This amount shall be deducted from the amount An attorney's fee of $ . claimant(s) is/are to receive, and paid directly to counsel. Employer and its insurance carrier, if any, shall pay the costs of this action. This is an award of the Industrial Commission and any interested party may give notice of appeal within the time and in the manner provided by law.
NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING AGREEMENT IS HEREBY APPROVED: CLAIMS EXAMINER

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FORM 30D 11/01 PAGE 1 OF 1

FORM 30D

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/