Common Contracts
1 similar Agreement for Compensation for Disability contracts
ContractAgreement for Compensation for Disability • February 26th, 2021
North Carolina Industrial Commission IC File # AGREEMENT FOR COMPENSATION FOR DISABILITY Emp. Code # Carrier Code # (G.S. § 97-82) Carrier File # The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act ( ) Employee’s Name Employer's Name Telephone Number Address Employer’s Address City State Zip City State Zip Insurance Carrier ( ) ( ) Home Telephone Work Telephone Carrier's Address City State Zip XXX-XX- □ M □ F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth Carrier's Telephone Number Fax Number
