Free North Carolina 62 Form
Contents
The North Carolina 62 form plays a crucial role in the state's workers' compensation process, specifically addressing the reinstatement or modification of compensation for injured employees. This form is mandated under North Carolina's Workers' Compensation Act, ensuring that both employers and insurance carriers adhere to the legal requirements when changes occur in an employee's compensation status. It captures essential details such as the employee's name, their average weekly wage, and the specific reasons for any adjustments to their compensation. The form also outlines the type of compensation being paid, whether it is temporary total or partial, and includes vital information like the dates of injury and the relevant insurance policy numbers. After completion, the original form must be submitted to the Industrial Commission, while copies are provided to the employee and their attorney, if applicable. Understanding the North Carolina 62 form is essential for both employers and employees navigating the complexities of workers' compensation claims.
Sample - North Carolina 62 Form
NORTH CAROLINA INDUSTRIAL COMMISSION
IC File #
NOTICE OF REINSTATEMENT OR MODIFICATION OF
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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Date of Injury:
Compensation in the amount of $ . |
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per week was reinstated or modified on |
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pursuant to |
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or
N.C. Gen. Stat. §
Give reason for reinstatement:
The employee's average weekly wage, including overtime and all allowances, was |
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which results 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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SIGNATURE EMPLOYER OR CARRIER/ADMINISTRATOR |
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Employer: The original of this form must be sent to the Industrial Commission at the address below. A copy shall be provided to the employee and the employee's attorney of record, if any.
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MAIL TO: NCIC - CLAIMS SECTION |
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FORM 62 |
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4335 MAIL SERVICE CENTER |
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RALEIGH, NC |
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10/2006 |
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PAGE 1 OF 1 |
FORM 62 |
TELEPHONE: (919) |
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HELPLINE: (800) |
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WEBSITE: HTTP://WWW.IC.NC.GOV/
File Breakdown
| Fact Name | Details |
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| Purpose | This form is used to notify the North Carolina Industrial Commission about the reinstatement or modification of workers' compensation benefits. |
| Governing Laws | The form is governed by North Carolina General Statutes § 97-32.1 and § 97-18(b). |
| Submission Requirements | The original form must be submitted to the Industrial Commission, with copies provided to the employee and their attorney, if applicable. |
| Contact Information | For inquiries, the North Carolina Industrial Commission can be reached at (919) 807-2502 or (800) 688-8349. |
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