Free Form 31 - North Carolina

North Carolina Industrial Commission
IC File #

APPLICATION FOR LUMP SUM AWARD

Emp. Code # Carrier Code # Carrier File #

The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address

Employer FEIN

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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

APPLICATION MUST BE COMPLETED IN FULL BEFORE REQUEST WILL BE CONSIDERED. The applicant represents that he or she has been granted an award of compensation by the North Carolina Industrial Commission, and that the award has been paid in periodical payments for not less than six weeks. The applicant hereby requests that he or she be allowed a lump-sum payment in an amount as requested below. (If the applicant desires to buy property of any kind with this lump sum settlement, three estimates of the value of the property must be submitted with the application to the Industrial Commission.) Name: Address: Present Employer: How Long: Job Title: Average Wage/Wk : Are you unemployed: Other Income (Including Spouse's):

Birth Date: Phone Number: Marital Status: Dependents (Names & Ages):

Outstanding Bills (Creditor and Amount Owed):

Purpose of Lump Sum Request: Amount Requested $ Applicant's Signature: Date:

Applicant must send a copy of this form to the carrier and a copy to the Industrial Commission at the address below. TO BE COMPLETED BY CARRIER/ADMINISTRATOR The (Name Insurance Company), agrees to pay the requested amount of $ in a lump sum without commutation, or agrees to pay the following recommended amount of $ without commutation or refuses to pay the compensation in a lump sum without commutation. Balance due applicant (pre-lump sum): For Commission's Use Only Approved By: Amount: Signature Denied By: Date:

in a lump sum

Title

MAIL TO:
FORM 31 2/01 PAGE 1 OF 1

FORM 31

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/