Form 23 - Application To Reinstate Payment Emp. Fein # Of Disability Compensation Page 2
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1
2I.C. N
. ___________
O
S
B. T
C
B
T
E
C
/A
ECTION
O BE
OMPLETED
Y
HE
MPLOYER OR
ARRIER
DMINISTRATOR
1. THE EMPLOYER/CARRIER MUST COMPLETE EITHER 1.(a) OR 1.(b)
(a) If reinstatement of compensation is not contested, complete the following:
Compensation in the amount of $__________ per week was or will be reinstated from __________/__________/__________
commencing on: _________/___________/__________
If compensation is reinstated on a date other than the date requested by the employee in Section A.5., please explain:________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
(b) Compensation should not be reinstated because:____________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
2. (a) Specify whether this claim has been accepted, denied or determined compensable by the Industrial Commission:_________
______________________________________________________________________________________________________
(b) How: Form 61
Form 21
Form 60
Form 63
Opinion and Award
Other___________________________________________________________
3. If compensation has been paid, provide the number of weeks: _______From:______/______/______To:______/______/______
I
,
F REINSTATEMENT OF COMPENSATION IS CONTESTED
GIVE A TELEPHONE NUMBER AT WHICH YOU CAN BE REACHED WHEN THE INFORMAL
,
M
F
8:00
.
.
5:00
.
. ______________________
HEARING IS SCHEDULED
FROM
ONDAY THROUGH
RIDAY BETWEEN
A
M
AND
P
M
AND A FACSIMILE
-
:
NUMBER OR E
MAIL ADDRESS FOR SERVICE OF THE HEARING NOTICE AND ANY OTHER CORRESPONDENCE
I
I
C
, I
,
N ADDITION TO FILING THE ORIGINAL OF THIS RESPONSE WITH THE
NDUSTRIAL
OMMISSION
HEREBY CERTIFY THAT A COPY OF THIS RESPONSE
,
’
,
,
TOGETHER WITH SUPPORTING DOCUMENTS
WAS SENT TO THE EMPLOYEE OR THE EMPLOYEE
S ATTORNEY OF RECORD
IF ANY
AT
(
/F
N
:)_________________________________________________________________________________________
ADDRESS
AX
O
________________________________________________________________________________________________________
_______________________________________________________________.
ON
S
E
,
IGNATURE OF
MPLOYER
C
/A
ARRIER
DMINISTRATOR OR
A
:_________________________________________________________________________D
:__________________
TTORNEY
ATE
A
/C
:
TTORNEYS
ARRIERS
F
E
D
F
P
ILE VIA
LECTRONIC
OCUMENT
ILING
ORTAL
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HTTP
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HTML
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ILING
PTIONS
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23
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MAIL TO EXECSEC
IC
NC
GOV
F
23
ORM
02/2016
F
(919) 715-0282
AX TO
2
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NCIC-E
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P
2
AGE
OF
AIL TO
XECUTIVE
ECRETARY
4333 M
S
C
AIL
ERVICE
ENTER
R
, NC 27699-4333
ALEIGH
H
: (800) 688-8349
ELPLINE
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