Free Form 29 - North Carolina

North Carolina Industrial Commission
IC File #

SUPPLEMENTAL REPORT FOR FATAL ACCIDENTS
(FORM 19, EMPLOYER'S REPORT OF EMPLOYEE'S INJURY TO THE INDUSTRIAL COMMISSION, MUST ALSO BE SUBMITTED IN EVERY CASE)
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. Code numbers assigned to each employer and carrier should be inserted before mailing.

(
Deceased 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

1. Date of accident:

2. Date of death:

, 20

3. Dependents, or if employee left no dependents, next of kin: (Indicate which are non-resident aliens) Name a. b. c. d. e. f. Date of Birth Relationship Present Address

4. Immediate cause of death:

5. Amount of burial expenses authorized $

Signature of Employer or Carrier/Administrator

Title

Date

MAIL TO:
FORM 29 2/01 PAGE 1 OF 1

FORM 29

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/