Last updated: 8/17/2020
Notice Of Reinstatement Or Modification Of Compensation {62}
Start Your Free Trial $ 13.99What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
North Carolina Industrial Commission IC File # NOTICE OF REINSTATEMENT OR MODIFICATION OF COMPENSATION (G.S. § 97-32.1 OR § 97-18(b)) The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Emp. Code # Carrier Code # Carrier File # Employer FEIN Employee's Name Address City ( ) Home Telephone XXX-XXLast 4 Digits of SSN Date of Injury: State ( ) Work Telephone // Date of Birth Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address ( ) Carrier's Telephone Number City ( ) Telephone Number State Zip Policy Number City ( ) State Zip M Sex F Fax Number . Compensation in the amount of $ pursuant to per week was reinstated or modified on N.C. Gen. Stat. § 97-32.1 or N.C. Gen. Stat. § 97-18(b). Give reason for reinstatement: The employee's average weekly wage, including overtime and all allowances, was . which results in a weekly compensation rate of $ . a. Temporary total compensation is being paid at the compensation rate above. . b. Temporary partial compensation is being paid in the amount of $ c. Other: $ . , . . / / SIGNATURE EMPLOYER OR CARRIER/ADMINISTRATOR TITLE DATE Employer: The original of this form must be sent to the Industrial Commission at the address below. A copy shall be provided to the employee and the employee's attorney of record, if any. FILE VIA ELECTRONIC DOCUMENT FILING PORTAL FORM 62 02/2017 PAGE 1 OF 1 HTTP://WWW.IC.NC.GOV/DOCFILING.HTML CONTACT INFORMATION: FORM 62 NCIC-CLAIMS ADMINISTRATION TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com
Related forms
-
Annual Consolidated Fiscal Report Of Medical Only Or Lost Time Cases
North Carolina/Workers Comp/ -
Application For Review Tort Award
North Carolina/Workers Comp/ -
Evaluation For Permanent Impairment
North Carolina/Workers Comp/ -
Petition To Appeal As An Indigent Person
North Carolina/Workers Comp/ -
Release Of Tort Claim
North Carolina/Workers Comp/ -
Response To Request That Claim Be Assigned For Hearing
North Carolina/Workers Comp/ -
Mediated Settlement Agreement
North Carolina/Workers Comp/ -
Certification Of Payment Of Processing Fee For Compromise Settlement Agreements
North Carolina/Workers Comp/ -
Mediated Settlement Agreement (Alternative Version)
North Carolina/Workers Comp/ -
Report Of Evaluator
North Carolina/Workers Comp/ -
Medical Provider Dispute Resolution Questionnaire
North Carolina/Workers Comp/ -
Subpoena
North Carolina/Workers Comp/ -
Petition To Sue As An Indigent Person
North Carolina/Workers Comp/ -
Application For Review
North Carolina/Workers Comp/ -
Claimants Petition For Compensation Erroneous Conviction
North Carolina/Workers Comp/ -
Nurses Section Referral Form
North Carolina/Workers Comp/ -
Report Of Employer Or Carrier Administrator Of Compensation And Medical Compensation
North Carolina/Workers Comp/ -
Employees Request That Compensation Be Reinstated After Unsuccessful Trial Return To Work
North Carolina/Workers Comp/ -
Notice Of Termination Of Compensation By Reason Of Trial Return To Work
North Carolina/Workers Comp/ -
Notice To The Commission Of Assignment Of Rehabilitation Professional
North Carolina/Workers Comp/ -
Notice Of Award
North Carolina/Workers Comp/ -
Report Of Employer Or Carrier Administrator Of Compensation And Medical Compensation Paid
North Carolina/Workers Comp/ -
Agreement For Payment Of Unpaid Compensation In Unrelated Death Cases
North Carolina/Workers Comp/ -
Itemized Statement Of Charges For Drugs
North Carolina/Workers Comp/ -
Award Approving Agreement For Compensation For Death
North Carolina/Workers Comp/ -
Application For Lump Sum Award
North Carolina/Workers Comp/ -
Supplemental Report For Fatal Accidents
North Carolina/Workers Comp/ -
Application For Appointment Of Guardian Ad Litem
North Carolina/Workers Comp/ -
Certificate Of Accrued Arrearages Or Certified Accounting Award
North Carolina/Workers Comp/ -
Notice To Employee Of Payment Of Compensation Without Prejudice
North Carolina/Workers Comp/ -
Employers Admission Of Employees Right To Compensation
North Carolina/Workers Comp/ -
Affidavit Of Accrued Arrearages
North Carolina/Workers Comp/ -
Statement Of Accrued Arrearages
North Carolina/Workers Comp/ -
Employees Application For Additional Medical Compensation
North Carolina/Workers Comp/ -
Denial Of Workers Compensation Claim
North Carolina/Workers Comp/ -
Notice Of Reinstatement Or Modification Of Compensation
North Carolina/Workers Comp/ -
Statement Of Days Worked And Earnings Of Injured Employee
North Carolina/Workers Comp/ -
Authorization For Rehabilitation Professional To Obtain Medical Records Of Current Treatment
North Carolina/Workers Comp/ -
Application To Terminate Or Suspend Payment Of Compensation
North Carolina/Workers Comp/ -
Request For Preauthorization Of Medical Treatment
North Carolina/5 Workers Comp/ -
Medical Status Questionnaire
North Carolina/5 Workers Comp/ -
Employers Report Of Employees Injury Or Occupational Disease To The Industrial Commission
North Carolina/Workers Comp/ -
Certification Of Payment Of Processing Fee For The Form 33I
North Carolina/5 Workers Comp/ -
Claim For Compensation Eugenics Asexualization And Sterilization Program
North Carolina/5 Workers Comp/ -
Motion To Reconsider Decision Of Deputy Commissioner Eugenics Asexualization And Sterilization Program
North Carolina/5 Workers Comp/ -
Request For Hearing Before Deputy Commissioner Eugenics Asesxualization And Sterilization Program
North Carolina/5 Workers Comp/ -
Notice Of Appeal To Full Commission Eugenics Asexualization And Sterilization Program
North Carolina/5 Workers Comp/ -
Notice Of Appeal To Court Of Appeals Eugenics Asexualization And Sterilization Program
North Carolina/5 Workers Comp/ -
Workers Compensation Notice To Injured Workers And Employers
North Carolina/Workers Comp/ -
Agreement For Compensation For Death
North Carolina/Workers Comp/ -
Report Of Earnings
North Carolina/Workers Comp/ -
Agreement For Compensation For Disability
North Carolina/Workers Comp/ -
Supplemental Agreement As To Payment Of Compensation
North Carolina/Workers Comp/ -
Application For Appointment Of Guardian Ad Litem
North Carolina/5 Workers Comp/ -
Claim For Damages Under Tort Claims Act
North Carolina/Workers Comp/ -
Intervenors Request That Claim Be Assigned For Hearing
North Carolina/Workers Comp/ -
Application To Reinstate Payment Of Disability Compensation
North Carolina/Workers Comp/ -
Claim For Benefits Under The Public Safety Employees Death Benefits Act
North Carolina/5 Workers Comp/ -
Consent Order For Mediated Settlement Conference
North Carolina/Workers Comp/ -
Petition For Order Referring Case To Mediated Settlement Conference
North Carolina/Workers Comp/ -
Report Of Mediator
North Carolina/Workers Comp/ -
Request That Claim Be Assigned For Hearing
North Carolina/Workers Comp/ -
Employers Admission Of Employees Right To Permanent Partial Disability
North Carolina/Workers Comp/ -
Return To Work Report
North Carolina/Workers Comp/ -
Itemized Statement Of Charges For Travel
North Carolina/Workers Comp/ -
Mediators Declaration Of Interest And Qualifications
North Carolina/Workers Comp/ -
Claim By Employee Representative Or Dependent For Benefits For Lung Disease
North Carolina/Workers Comp/ -
Designation Of Mediator
North Carolina/Workers Comp/ -
Order For Mediated Settlement Conference
North Carolina/Workers Comp/ -
Notice Of Accident To Employer And Claim Of Employee Representative Or Dependent
North Carolina/Workers Comp/
Form Preview
Contact Us
Success: Your message was sent.
Thank you!