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Get Industrial Commission Form 31 2016-2024

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 Birth Date Phone Number Marital Status Dependents Names Ages Present Employer How Long Job Title Average Wage/Wk Are you unemployed Other Income Including Spouse s 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 The Name Insurance Company agrees to pay the requested amount of 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 MAIL TO FORM 31 2/01 PAGE 1 OF 1 in a lump sum Title NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH NC 27699-4335 MAIN TELEPHONE 919 807-2500 HELPLINE 800 688-8349 WEBSITE HTTP //WWW.IC. 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 Employer FEIN Employee s Name Address Employer s Address City State Home Telephone Sex Zip Insurance Carrier Work Telephone M Social Security Number Telephone Number F / Date of Birth Carrier s Address Carrier s Telephone Number Fax 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 Birth Date Phone Number Marital Status Dependents Names Ages Present Employer How Long Job Title Average Wage/Wk Are you unemployed Other Income Including Spouse s 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 The Name Insurance Company agrees to pay the requested amount of 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 MAIL TO FORM 31 2/01 PAGE 1 OF 1 in a lump sum Title NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH NC 27699-4335 MAIN TELEPHONE 919 807-2500 HELPLINE 800 688-8349 WEBSITE HTTP //WWW*IC.

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