North Carolina Workers' Compensation Employer Admission Form
This document is the North Carolina Industrial Commission Employer's Admission of Employee's Right to Compensation. It details the necessary information for compensability of a workers' compensation claim. This form is required under the Workers' Compensation Act.
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How do I fill this out?
Filling out this form requires providing detailed information regarding the employee, employer, injury, and compensation terms. Ensure all fields are accurately completed to avoid penalties. Follow the instructions carefully to complete the admission process.
How to fill out the North Carolina Workers' Compensation Employer Admission Form?
1
Enter the employee and employer details.
2
Provide information about the injury or occupational disease.
3
Detail the compensation rates and type of compensation.
4
Sign the form as the employer or carrier/administrator.
5
Submit the form via the specified method.
Who needs the North Carolina Workers' Compensation Employer Admission Form?
1
Employers in North Carolina needing to admit liability for a workers' compensation claim.
2
Insurance carriers handling workers' compensation cases in North Carolina.
3
Employees of North Carolina seeking admission of their right to compensation.
4
Legal representatives managing workers' compensation claims.
5
HR departments processing workers' compensation documentation.
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What are the instructions for submitting this form?
Submit the completed form via the NCIC Electronic Document Filing Portal at http://www.ic.nc.gov/docfiling.html. For assistance, contact NCIC Claims Administration at (919) 807-2502 or the helpline at (800) 688-8349. Alternatively, mail to: NC Industrial Commission, 1236 Mail Service Center, Raleigh, NC 27699-1236. Ensure all fields are accurately completed to avoid delays or penalties. Save a copy of the completed form for your records. Contact the NCIC directly if you encounter any issues during submission.
What are the important dates for this form in 2024 and 2025?
File Form 60 within 16 days of the last payment pursuant to an agreement or award to avoid penalties.
What is the purpose of this form?
The purpose of this form is to officially document an employer's admission of liability for a workers' compensation claim in North Carolina. This form is used to detail the specifics of the injury or occupational disease, including the compensation rates and terms agreed upon between the employer and employee. Proper completion and submission of this form ensure compliance with the North Carolina Workers' Compensation Act and protect both parties' legal rights.
Tell me about this form and its components and fields line-by-line.
- 1. IC File #: Identification number assigned by the Industrial Commission.
- 2. Emp. Code #: Employer's code number for internal reference.
- 3. Carrier Code #: Insurance carrier's code number.
- 4. Carrier File #: File number assigned by the insurance carrier.
- 5. Employee's Name: Name of the employee involved in the workers' compensation claim.
- 6. Employer's Name: Name of the employer admitting liability.
- 7. Employer's Address: Physical address of the employer.
- 8. Home Telephone: Employee's home telephone number.
- 9. Work Telephone: Employee's work telephone number.
- 10. Last 4 Digits of SSN: Last four digits of the employee's Social Security Number.
- 11. Sex: Employee's gender.
- 12. Date of Birth: Employee's date of birth.
- 13. Insurance Carrier: Name of the insurance carrier handling the claim.
- 14. Carrier's Address: Physical address of the insurance carrier.
- 15. Carrier's Telephone Number: Telephone number of the insurance carrier.
- 16. Policy Number: Insurance policy number relevant to the claim.
- 17. Body Part(s) or Condition(s): Detailed description of the injured body part(s) or occupational disease.
- 18. Date of Injury: Date when the injury occurred.
- 19. Compensation Rates and Types: Details the compensation rates and types agreed upon.
- 20. Employer/Administrator Signature: Signature of the employer or carrier/administrator.
- 21. Submission Instructions: Instructions on how and where to submit the completed form.
- 22. Contact Information: Contact details for further assistance and submission queries.
What happens if I fail to submit this form?
Failure to submit this form can result in penalties under N.C. Gen. Stat. § 97-18(h).
- Penalties: Monetary fines for non-compliance.
- Legal Repercussions: Potential legal issues for failing to acknowledge liability.
How do I know when to use this form?
- 1. Workplace Injuries: Admitting liability for injuries sustained in the workplace.
- 2. Occupational Diseases: Documenting compensable occupational diseases.
- 3. Legal Requirements: Meeting legal requirements for workers' compensation admissions.
- 4. Insurance Claims: Processing claims with the insurance carrier.
- 5. Employee Communication: Informing employees of their right to compensation.
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