ContractSupplemental Agreement as to Payment of Compensation • October 11th, 2021
North Carolina Industrial Commission IC File # SUPPLEMENTAL AGREEMENT AS TO PAYMENT Emp. Code # OF COMPENSATION (G.S. § 97-82) Carrier Code # The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Carrier File #Supplemental Agreement as to Payment of Compensation • March 2nd, 2020
( ) 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
Supplemental Agreement as to Payment Emp. Code #Supplemental Agreement as to Payment of Compensation • June 19th, 2018
ContractSupplemental Agreement as to Payment of Compensation • March 2nd, 2020
North Carolina Industrial Commission IC File # Supplemental Agreement as to Payment Emp. Code # of Compensation (G.S. § 97-82) Carrier Code # The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Carrier File #
North Carolina Industrial Commission IC File # SUPPLEMENTAL AGREEMENT AS TO PAYMENT Emp. Code # OF COMPENSATION (G.S. § 97-82) Carrier Code # The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Carrier File #Supplemental Agreement as to Payment of Compensation • February 26th, 2021
( ) 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
ContractSupplemental Agreement as to Payment of Compensation • January 7th, 2021
