Free Form 30A - North Carolina

North Carolina Industrial Commission
IC File #

NOTICE OF AWARD

Emp. Code # Employer FEIN Carrier File #

The Use of This Form Is Required Under The Provisions of the Workers' Compensation Act.

Carrier Code #

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Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address

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Telephone Number City State Zip

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) (M) (F)

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City State Fax Number Zip

Home Telephone Social Security Number Sex

Work Telephone

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Date of Birth

Carrier's Telephone Number

The above parties have previously submitted an agreement for compensation for disability or death on Form . The Commission entered an award in the case upon receipt of the agreement. The Commission has now been informed that . Therefore, the original award is amended as follows:

As above mentioned, said Agreement is hereby approved. This is a formal award of the Industrial Commission. Any interested party may give notice of appeal therefrom within fifteen (15) days or receipt of this award.

SIGNATURE

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DATE

FORM 30A 8/08 PAGE 1 OF 1

FORM 30A

MAIL TO: NCIC - CLAIMS ADMINISTRATION 4335 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/