North Carolina Form 60 PDF Details

In the landscape of workers' rights and employer obligations, the North Carolina Industrial Commission's Form 60 emerges as a crucial document that formalizes an employer’s admission of an employee’s entitlement to compensation for injuries or diseases sustained in the workplace. This mandated form underscores the provisions under the Workers' Compensation Act, delineating a structured pathway for acknowledging workplace accidents or occupational diseases. It serves as a significant step in the process, requiring detailed information such as the employer’s and employee’s names, contact details, and specifics about the insurance policy. Furthermore, the form demands precision in describing the injury or disease, including the affected body parts, thereby establishing a clear basis for compensation claims. Intrinsically, it outlines the compensation agreed upon, detailing the average weekly wage and the resultant weekly compensation rate, alongside noting whether temporary total or partial compensation is being paid. Importantly, the document also marks the commencement of disability and compensation payments, setting a timeline for these benefits. By providing guidelines for both employers and employees, Form 60 plays a pivotal role in ensuring that workers are fairly compensated for work-related injuries or diseases, reinforcing the legal framework designed to protect workers’ rights while imposing specific responsibilities on employers. Additionally, it highlights the ongoing commitment to workplace safety and the welfare of employees, prompting a timely and accurate response to unfortunate incidents of workplace injuries or illnesses.

QuestionAnswer
Form NameNorth Carolina Form 60
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescompensable, particularity, RALEIGH, HTTP

Form Preview Example

NORTH CAROLINA INDUSTRIAL COMMISSION

IC File #

EMPLOYERS ADMISSION OF EMPLOYEES RIGHT TO

COMPENSATION (G.S. §97-18(B))

Emp. Code #

Carrier Code # Carrier File #

The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Employer FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

-

 

 

Employee’s Name

 

 

 

 

 

Employer’s Name

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

Employer’s Address

City

 

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

 

Zip

Insurance Carrier

Policy Number

 

 

( )

-

 

(

)

-

 

 

 

 

 

 

 

 

 

 

Home Telephone

 

Work Telephone

 

Carrier’s Address

City

 

 

State

Zip

 

-

-

M

F

/

/

 

( )

-

( )

-

 

 

 

 

Social Security Number

Sex

 

Date of Birth

 

Carrier’s Telephone Number

Fax Number

 

 

 

TO DEFENDANTS: Describe with particularity the body part(s) or condition(s) for which you are admitting liability and compensability.

TO EMPLOYEE: Your employer admits your right to compensation for an

injury by accident on /

/

(date) (Specify body part(s) involved):

 

 

 

 

 

occupational disease on

/ /

 

(date) (Specify condition(s) and body part(s) involved):

THE FOLLOWING ITEMS 1 THROUGH 4 ARE PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE AN AGREEMENT:

1.The description of the injury or occupational disease, including body parts involved is:

2.The employee was paid for the entire day of injury.

Yes

No

3.

The employee's average weekly wage, subject to verification, 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:

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

The disability resulting from the injury began on / /

(date), and compensation commenced on / /

 

(date).

 

 

 

 

 

 

 

 

 

/

 

/

SIGNATURE OF EMPLOYER OR CARRIER/ADMINISTRATOR

 

 

TITLE

DATE

EMPLOYER: Failure to file Form 28B, Report of Compensation and Medical Compensation Paid, within 16 days after last payment pursuant to an agreement or award subjects employer or carrier/administrator to a penalty pursuant to N.C. Gen. Stat. §97-18(h). Form 30 must be used for compensable injuries resulting in death. A copy of this Form 60 shall be provided to the employee and the employee's attorney of record, if any, and the original provided to the Industrial Commission at the address below.

 

 

SELF-INSURED EMPLOYER OR CARRIER MAIL TO:

FORM 60

 

NCIC - CLAIMS ADMINISTRATION

8/1/08

 

4335 MAIL SERVICE CENTER

PAGE 1 OF 1

FORM 60

RALEIGH, NORTH CAROLINA 27699-4335

 

MAIN TELEPHONE: (919) 807-2500

 

 

HELPLINE: (800) 688-8349

 

 

WEBSITE: HTTP://WWW.IC.NC.GOV/