Free Form 87C - North Carolina

North Carolina Industrial Commission

IC File #

CERTIFICATE OF ACCRUED ARREARAGES OR CERTIFIED ACCOUNTING OF AWARD G.S. 97-87
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Employer FEIN
The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence..

I.C. No. ____________; _________________, Employee, Plaintiff; v. _________________________, Employer; and __________________________ Carrier; Defendants. FILED: The undersigned, upon application of claimant and pursuant to N.C. Gen. Stat. § 97-87, enters a Certificate of Accrued Arrearages or Certified Accounting of an Award of the Commission as follows: 1. Provide the names and addresses of plaintiff, liable defendant-employer (and 3rd party administrator if applicable) and liable defendant-carrier.
Claimant
Name Address City, State, Zip Code

Employer-Defendant
Name Address City, State, Zip Code

Carrier-Defendant or 3rd Party Administrator
Name Address City, State, Zip Code

2. The sum of all principal amounts that have accrued and remain unpaid since the date of the award or since the date of the most recent prior Certificate of Accrued Arrearages is: $ ________________. 3. The total of any interest that has accrued and remains unpaid since the date of the award or since the date of the most recent prior Certificate of Accrued Arrearages is: $ . 4. Costs, penalties, or monetary sanctions previously awarded are: $ 5. The total sum remaining unpaid as of
Date of Application

. .

is $

The above named defendant(s) is/are jointly and severally liable and judgment shall be entered against all defendants. The undersigned hereby certifies that the information contained herein is a true accounting of the accrued arrearages due claimant pursuant to an Award of the Commission in this claim. This the day of , 20 .
_____________________________________________ COMMISSIONER

MAIL TO: THE FULL COMMISSION FORM 87C 07/08 PAGE 1 OF 1

FORM 87C

NORTH CAROLINA INDUSTRIAL COMMISSION 4336 MAIL SERVICE CENTER RALEIGH, NC 27699-4336