Free Microsoft Word - form61.dot - North Carolina

North Carolina Industrial Commission
IC File #

DENIAL OF WORKERS' COMPENSATION CLAIM (G.S. §97-18(c) AND G.S. §97-18(d))
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Carrier File # Employer FEIN
( ) Telephone Number City Policy Number City ( ) State Zip State Zip

Employee's Name Address City ( ) Home Telephone - Social Security Number Date of Injury: State ( ) Work Telephone / / Date of Birth Zip

Employer's Name Employer's Address Insurance Carrier Carrier's Address ( ) Carrier's Telephone Number

M Sex

F

Fax Number

TO EMPLOYEE (TO DEPENDENT(S) OR NEXT OF KIN IN CASE OF DEATH): This is to inform you that the claim for the injury on occupational disease as of death on , or , or

is DENIED for the following reasons:

/
SIGNATURE EMPLOYER OR CARRIER/ADMINISTRATOR TITLE

/

DATE

Employer/Insurance Carrier must provide a detailed statement of the grounds for denying compensability of the claim or liability for the claim where payments have previously been made without prejudice under N.C. Gen. Stat. § 97-18(d). Failure to specify a particular ground may preclude asserting certain defenses at a later date pursuant to N.C. Gen. Stat. § 97-18(f).
Employee: If you disagree with this denial, you are entitled to request a hearing by submitting a Form 33. If you need assistance you may contact the Industrial Commission at the address below or telephone the Industrial Commission at (800) 688-8349. Employer: A copy of this form shall be sent to the employee and employee's attorney of record, if any, and all known health care providers which have submitted bills to the employer/carrier. The original of this form shall be sent to the Industrial Commission at the address below.

MAIL TO:
FORM 61 10/2006 PAGE 1 OF 1

FORM 61

NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH, NC 27699-4335 TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/