Free Form 30 - North Carolina

North Carolina Industrial Commission
IC File #

AGREEMENT FOR COMPENSATION FOR DEATH
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Employer FEIN

(
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

We, the dependent(s) or next of kin listed below and the employer and carrier/administrator hereby stipulate to the following facts as to the death of the deceased employee: 1. The employer and the deceased employee were bound by the provisions of the N.C. Workers' Compensation Act; 2. The deceased employee sustained a compensable injury by accident (or occupational disease) on that arose out of and in the course of his employment and resulted in his death on 3. The average weekly wage of deceased employee was $ , , . . ,

, and the weekly compensation rate is $

4. The parties hereto have provided the Industrial Commission with the names and addresses of all known persons wholly or partially dependent for support upon the earnings of the deceased employee at the time of the accident, or the next of kin who might be entitled to compensation if there are no whole or partial dependents. 5. The following are the only persons entitled to receive compensation as a result of the death of employee: Indicate whole or partial dependent or next of kin

Name

Address

Date of Birth

Age

Relationship

(IF ADDITIONAL SPACE NEEDED USE REVERSE SIDE) 6. Based upon the above stipulated facts, the employer and its carrier or third party administrator, agree to pay and the dependents, or next of kin agree to accept compensation based upon a weekly rate of $ payable as follows: (Check all that apply) if widow/widower only, for 400 weeks if widow/widower and minor child(ren), in equal shares for 400 weeks; however, minor child(ren) shall continue to receive compensation if they have not yet reached age 18 within the 400 week period if minor child(ren) only, in equal shares for 400 weeks or until they reach age 18, whichever is longer If whole dependent(s) other than widow/widower and/or child(ren), for 400 weeks if partial dependent(s) only, in the weekly amount of $ (compensation rate multiplied by the percentage of support provided by deceased) for 400 weeks

MAIL TO:
FORM 30 11/01 PAGE 1 OF 2

FORM 30

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/

if next of kin, for 400 weeks payable in a lump sum commuted to present value in equal shares

7. The parties agree that the employee's surviving widow/widower was able or was unable to support herself/himself because of physical or mental disability as of the date of death of the employee, and will or will not continue to receive additional weekly benefits during his/her lifetime or until remarriage.

8. The employer and its carrier agree to pay burial expenses not exceeding $3,500.00 for deaths on or after October 1, 2001, and medical expenses in accordance with Commission procedure. 9. Compensation for death to be paid under this agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Amount due for expense of burial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Total amount to be paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

10. The date of this agreement is

, 20

.

Signature of Dependent or Next of Kin

Signature of Employer

Title

Signature of Dependent or Next of Kin Signature of Carrier/Administrator Signature of Dependent or Next of Kin Title

Signature of Dependent or Next of Kin

Signature of Plaintiff's Attorney

NOTICE TO EMPLOYER OR CARRIER: A completed Form 30D Award Approving Agreement for Compensation for Death or a document containing all pertinent information MUST be submitted to the Industrial Commission along with this Form 30 Agreement for Compensation for Death. In addition, the following documents, if appropriate, should be attached to this Form: (1) death certificate; (2) marriage certificate; (3) divorce decree; (4) birth certificate, if minor; (5) Form 42 Application for Appointment of Guardian Ad Litem; and (6) Form 29 Supplemental Report for Fatal Accidents.

MAIL TO:
FORM 30 11/01 PAGE 2 OF 2

FORM 30

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/