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Free North Carolina 60 Form

The North Carolina 60 form is an official document used by employers to acknowledge an employee's right to compensation under the state's Workers' Compensation Act. This form serves as a formal admission of liability for specific injuries or occupational diseases sustained by an employee. Understanding the details and requirements of this form is crucial for both employers and employees to ensure compliance and protection of rights.

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Contents

The North Carolina 60 form, officially known as the Employer’s Admission of Employee’s Right to Compensation, plays a crucial role in the state's workers' compensation process. This form is utilized by employers to formally acknowledge an employee's right to receive compensation for work-related injuries or occupational diseases. It requires the employer to provide essential information, including the employee's name, the nature of the injury, and details regarding the compensation rate. Notably, the form captures specifics about the injury, such as the body parts affected and the dates relevant to the incident. Additionally, it serves as a record of the employee’s average weekly wage and outlines the types of compensation being paid, whether temporary total or partial. The form also emphasizes the importance of compliance, stating that failure to file the necessary reports within designated timelines may result in penalties. It is essential for both employers and employees to understand the implications of this form, as it not only facilitates the compensation process but also ensures that all parties are informed of their rights and responsibilities under North Carolina's Workers' Compensation Act.

Sample - North Carolina 60 Form

NORTH CAROLINA INDUSTRIAL COMMISSION

IC File #

EMPLOYER’S ADMISSION OF EMPLOYEE’S 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

( )

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

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:

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
	FORM 60	MAIN TELEPHONE: (919) 807-2500
		HELPLINE: (800) 688-8349
		WEBSITE: HTTP://WWW.IC.NC.GOV/

⇩ North Carolina 60 PDF Form

File Breakdown

Fact Name	Fact Description
Governing Law	The North Carolina 60 form is governed by G.S. §97-18(B) of the Workers' Compensation Act.
Purpose	This form is used for an employer's admission of an employee's right to compensation for work-related injuries.
Information Required	Employers must provide details such as employee name, injury description, and compensation amounts.
Filing Deadline	Employers must file Form 28B within 16 days after the last payment to avoid penalties.
Compensation Types	Employers can indicate temporary total or partial compensation amounts on the form.
Employee Notification	A copy of the Form 60 must be given to the employee and their attorney, if applicable.
Contact Information	The form provides contact details for the North Carolina Industrial Commission for any inquiries.
Submission Address	The original form must be sent to the NCIC Claims Administration at 4335 Mail Service Center, Raleigh, NC 27699-4335.

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