North Carolina Industrial Commission
IC File # Emp. Code # Carrier Code # Carrier File # Employer FEIN
REPORT OF EMPLOYER OR CARRIER/ADMINISTRATOR OF COMPENSATION AND MEDICAL COMPENSATION PAID PURSUANT TO A COMPROMISE SETTLEMENT AGREEMENT
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
THIS FORM IS ONLY TO BE USED IN SETTLED CASES
(
Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address City State Fax Number Zip City
)
Telephone Number State Zip
(
) M F
( /
) / ( ) ( )
Home Telephone Social Security Number Sex
Work Telephone Date of Birth
Carrier's Telephone Number
1. 2. 3.
Date of accident or disability from occupational disease ________________________________________. Salary was / was not continued. Total Dollar Amount
Number of weeks temporary total
_____ from ______________ , through ______________ $______________ _____ from ______________ , through ______________ $______________
4.
Number of weeks temporary partial _____ from ______________ , through ______________ $______________ _____ from ______________ , through ______________ $______________
5. 6. 7. 8. 9. 10.
Number of weeks permanent partial _____ from ______________ , through ______________ $______________ Disfigurement amount paid Loss of organ or body part benefits paid TOTAL OF LINES 3 THROUGH 7 Compromise Settlement Agreement amount Total Medical Paid $______________ $______________ $______________ $______________ $______________
NAME OF EMPLOYER OR CARRIER/ADMINISTRATOR
SIGNATURE
TITLE
DATE
This form must be filed with the Industrial Commission at the address below.
FOR INDUSTRIAL COMMISSION USE ONLY Days Medical IC Code: ____________________ $____________________ ____________________ Compensation Paid $____________________
FORM 28C 11/2003 PAGE 1 OF 1
MAIL TO:
NCIC - STATISTICS SECTION 4334 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4334
FORM 28C
MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/