North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter A - WORKERS' COMPENSATION RULES › Section .0400 - DISABILITY, COMPENSATION, FEES › Section 23A .0409 - CLAIMS FOR DEATH BENEFITS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) An
				  employer shall notify the Commission of the occurrence of a death resulting
				  from an injury or occupational disease allegedly arising out of and in the
				  course of employment by filing a Form 19 Employer's Report of Employee's Injury
				  or Occupational Disease to the Industrial Commission within five days of
				  knowledge of the death.
(b) An
				  employer, carrier, or administrator shall conduct an investigation to determine
				  the names and addresses of decedent's potential beneficiaries under
				  G.S.
				  97-38 and identify them on the Form 29
				  Supplemental Report for Fatal Accidents. The Form 29 Supplemental Report for
				  Fatal Accidents shall be filed with the Commission within 45 days of
				  notification of a death or allegation of death resulting from an injury or
				  occupational disease arising out of and in the course of employment.
(c) If the employer, carrier, or
				  administrator disputes that an employee's death is compensable or denies it has
				  liability for the claim, the employer, carrier, or administrator shall notify
				  the Commission on a Form 61 Denial of Workers' Compensation Claim. When the
				  employer, carrier, or administrator denies liability for a claim involving an
				  employee's death, the employer, carrier, or administrator shall send the form
				  to all known potential beneficiaries, their attorneys of record, if any, all
				  health care providers that have submitted bills to the employer, carrier, or
				  administrator, and the Commission.
(d) If the employer, carrier, or
				  administrator accepts liability for a claim involving an employee's death and
				  there are no issues necessitating a hearing for determination of beneficiaries
				  or their respective rights, the parties shall submit either a Form 30 Agreement
				  for Compensation for Death as set forth in Rule .0501 of this Subchapter or a
				  proposed Opinion and Award.
(e) If
				  the parties submit a Form 30 Agreement for Compensation for Death, the
				  agreement shall be filed in accordance with Rule .0108 of this Subchapter with
				  the following:
(1) a stipulation as to average
				  weekly wage;
(2) any affidavits
				  regarding dependents;
(3) the
				  employee's death certificate;
(4) a
				  Form 29 Supplemental Report for Fatal Accidents;
(5) a Form 42 Application for Appointment of
				  Guardian ad Litem, if any beneficiary is a minor or incompetent;
(6) proof of beneficiary status, such as
				  marriage license, birth certificate, or divorce decree;
(7) a funeral bill or stipulation as to
				  payment of the funeral benefit;
(8)
				  a Form 30D Award Approving Agreement for Compensation for Death; and
(9) an affidavit or itemized statement in
				  support of an award of attorney's fees if an attorney is seeking fees for
				  representation of one or more beneficiaries.