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North Carolina Industrial Commission
IC File #

NOTICE OF REINSTATEMENT OR MODIFICATION OF COMPENSATION (G.S. §97-32.1 OR §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

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 City

( ) Telephone Number State Zip

Policy Number City ( ) State Zip

M Sex

F

Fax Number

. Compensation in the amount of $ pursuant to

per week was reinstated or modified on N.C. Gen. Stat. § 97-32.1 or N.C. Gen. Stat. § 97-18(b).

Give reason for reinstatement:

The employee's average weekly wage, including overtime and all allowances, was . which results in a weekly compensation rate of $ . a. Temporary total compensation is being paid at the compensation rate above. . b. Temporary partial compensation is being paid in the amount of $ c. Other:

$

.

,

. . / /

SIGNATURE EMPLOYER OR CARRIER/ADMINISTRATOR

TITLE

DATE

Employer: The original of this form must be sent to the Industrial Commission at the address below. A copy shall be provided to the employee and the employee's attorney of record, if any.

MAIL TO:
FORM 62 10/2006 PAGE 1 OF 1

FORM 62

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/