North Carolina Industrial Commission
IC File #
NOTICE OF AWARD
Emp. Code # Employer FEIN Carrier File #
The Use of This Form Is Required Under The Provisions of the Workers' Compensation Act.
Carrier Code #
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Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address
)
Telephone Number City State Zip
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) (M) (F)
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City State Fax Number Zip
Home Telephone Social Security Number Sex
Work Telephone
/
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)
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Date of Birth
Carrier's Telephone Number
The above parties have previously submitted an agreement for compensation for disability or death on Form . The Commission entered an award in the case upon receipt of the agreement. The Commission has now been informed that . Therefore, the original award is amended as follows:
As above mentioned, said Agreement is hereby approved. This is a formal award of the Industrial Commission. Any interested party may give notice of appeal therefrom within fifteen (15) days or receipt of this award.
SIGNATURE
TITLE
DATE
FORM 30A 8/08 PAGE 1 OF 1
FORM 30A
MAIL TO: NCIC - CLAIMS ADMINISTRATION 4335 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/