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.
Question | Answer |
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Form Name | North Carolina Form 60 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | compensable, particularity, RALEIGH, HTTP |
NORTH CAROLINA INDUSTRIAL COMMISSION
IC File #
EMPLOYER’S ADMISSION OF EMPLOYEE’S RIGHT TO
COMPENSATION (G.S.
Emp. Code #
Carrier Code # Carrier File #
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act |
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Employee’s Name |
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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 / |
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(date) (Specify body part(s) involved): |
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occupational disease on |
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(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
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The employee's average weekly wage, subject to verification, including overtime and all allowances, was $ |
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in a weekly compensation rate of $ |
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a. Temporary total compensation is being paid at the compensation rate above. |
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b. Temporary partial compensation is being paid in the amount of $ |
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c. Other: |
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The disability resulting from the injury began on / / |
(date), and compensation commenced on / / |
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SIGNATURE OF EMPLOYER OR CARRIER/ADMINISTRATOR |
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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.
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FORM 60 |
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NCIC - CLAIMS ADMINISTRATION |
8/1/08 |
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4335 MAIL SERVICE CENTER |
PAGE 1 OF 1 |
FORM 60 |
RALEIGH, NORTH CAROLINA |
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MAIN TELEPHONE: (919) |
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HELPLINE: (800) |
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WEBSITE: HTTP://WWW.IC.NC.GOV/ |