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North Carolina Industrial Commission
IC File #

EMPLOYER'S ADMISSION OF EMPLOYEE'S RIGHT TO COMPENSATION (G.S. §97-18(b))
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Carrier File # Employer FEIN

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

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Telephone Number State Zip

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Sex

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State Zip

Home Telephone Social Security Number

Work Telephone Date of Birth

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Carrier's Telephone Number

Fax Number

TO DEFENDANTS: Describe with particularity the body part(s) or condition(s) for which you are admitting liability and compensability. TO EMPLOYEE: Your employer admits your right to compensation for an injury by accident on / / (date) (Specify body part(s) involved):

occupational disease on

/

/

(date) (Specify condition(s) and body part(s) involved):

THE FOLLOWING ITEMS 1 THROUGH 4 ARE PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE AN AGREEMENT: 1. The description of the injury or occupational disease, including body parts involved is:

2. 3.

The employee was paid for the entire day of injury.

Yes

No , which results

The employee's average weekly wage, subject to verification, including overtime and all allowances, was $ . in a weekly compensation rate of $ a. Temporary total compensation is being paid at the compensation rate above. b. c. Temporary partial compensation is being paid in the amount of $ Other: / / (date), and compensation commenced on / / .

4.

The disability resulting from the injury began on

(date).

/
SIGNATURE OF EMPLOYER OR CARRIER/ADMINISTRATOR TITLE

/
DATE

EMPLOYER: Failure to file Form 28B, Report of Compensation and Medical Compensation Paid, within 16 days after last payment pursuant to an agreement or award subjects employer or carrier/administrator to a penalty pursuant to N.C. Gen. Stat. §97-18(h). Form 30 must be used for compensable injuries resulting in death. A copy of this Form 60 shall be provided to the employee and the employee's attorney of record, if any, and the original provided to the Industrial Commission at the address below.
SELF-INSURED EMPLOYER OR CARRIER MAIL TO:

FORM 60 8/1/08 PAGE 1 OF 1

NCIC - CLAIMS ADMINISTRATION
4335 MAIL SERVICE CENTER

FORM 60

RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/