Agreement for Compensation for Disability Sample Contracts

SUBCHAPTER 23L – INDUSTRIAL COMMISSION FORMS
Agreement for Compensation for Disability • May 18th, 2021
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SUBCHAPTER 23L – INDUSTRIAL COMMISSION FORMS
Agreement for Compensation for Disability • June 4th, 2023
Sample 1
Contract
Agreement for Compensation for Disability • November 17th, 2020
Sample 1
Contract
Agreement 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

Sample 1
SUBCHAPTER 23L – INDUSTRIAL COMMISSION FORMS SECTION .0100 – WORKERS’ COMPENSATION FORMS
Agreement for Compensation for Disability • January 7th, 2021
Sample 1
North Carolina Industrial Commission
Agreement for Compensation for Disability • June 19th, 2018
Sample 1
Contract
Agreement for Compensation for Disability • March 2nd, 2020

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

Sample 1
Contract
Agreement for Compensation for Disability • March 2nd, 2020

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

Sample 1
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