Application For Lump Sum Award {31}

North Carolina Industrial Commission IC File # APPLICATION FOR LUMP SUM AWARD Emp. Code # Carrier Code # Carrier File # The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address Employer FEIN ( ) Telephone Number City State Zip ( ) M F ( / ) City State Fax Number Zip Home Telephone Social Security Number Sex Work Telephone / ( ) ( ) Date of Birth Carrier's Telephone Number APPLICATION MUST BE COMPLETED IN FULL BEFORE REQUEST WILL BE CONSIDERED. The applicant represents that he or she has been granted an award of compensation by the North Carolina Industrial Commission, and that the award has been paid in periodical payments for not less than six weeks. The applicant hereby requests that he or she be allowed a lump-sum payment in an amount as requested below. (If the applicant desires to buy property of any kind with this lump sum settlement, three estimates of the value of the property must be submitted with the application to the Industrial Commission.) Name: Address: Present Employer: How Long: Job Title: Average Wage/Wk : Are you unemployed: Other Income (Including Spouse's): Birth Date: Phone Number: Marital Status: Dependents (Names & Ages): Outstanding Bills (Creditor and Amount Owed): Purpose of Lump Sum Request: Amount Requested $ Applicant's Signature: Date: Applicant must send a copy of this form to the carrier and a copy to the Industrial Commission at the address below. TO BE COMPLETED BY CARRIER/ADMINISTRATOR (Name Insurance Company), agrees to pay the requested amount of $ The in a lump sum without commutation, or agrees to pay the following recommended amount of $ without commutation or refuses to pay the compensation in a lump sum without commutation. Balance due applicant (pre-lump sum): For Commission's Use Only Approved By: Amount: Signature Denied By: Date: in a lump sum Title EMAIL TO FORMS@IC.NC.GOV FORM 31 02/2016 PAGE 1 OF 1 CONTACT INFORMATION: FORM 31 NCIC-CLAIMS ADMINISTRATION TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com