C A A C A A G.S. 97-87
F
ORM
87C
07/08
P
AGE
1
OF
1
MAIL
TO:
F
ORM
87C
T
HE
F
ULL
C
OMMISSION
N
ORTH
C
AROLINA
I
NDUSTRIAL
C
OMMISSION
4336
M
AIL
S
ERVICE
C
ENTER
R
ALEIGH
,
NC
27699-4336
North Carolina Industrial Commission
IC File #
C
ERTIFICATE OF
A
CCRUED
A
RREARAGES
Emp. Code #
OR
C
ERTIFIED
A
CCOUNTING OF
A
WARD
Carrier Code #
G.S.
97-87
Employer FEIN
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
The I.C. File # is the unique identifier for this
injury. It will be provided by return letter and is to
be referenced in all future correspondence..
I.C. No. ____________; _________________, Employee, Plaintiff; v. _________________________,
Employer; and __________________________ Carrier; Defendants.
FILED:
The undersigned, upon application of claimant and pursuant to N.C. Gen. Stat. § 97-87, enters a
Certificate of Accrued Arrearages or Certified Accounting of an Award of the Commission as follows:
1. Provide the names and addresses of plaintiff, liable defendant-employer (and 3rd party administrator
if applicable) and liable defendant-carrier.
Claimant
Employer-Defendant
Name Address City, State, Zip Code
Carrier-Defendant or
3rd Party Administrator
Name Address City, State, Zip Code
Name Address City, State, Zip Code
2. The sum of all principal amounts that have accrued and remain unpaid since the date of the award or
since the date of the most recent prior Certificate of Accrued Arrearages is: $ ________________.
3. The total of any interest that has accrued and remains unpaid since the date of the award or since the
date of the most recent prior Certificate of Accrued Arrearages is: $ .
4. Costs, penalties, or monetary sanctions previously awarded are: $ .
5. The total sum remaining unpaid as of is $ .
Date of Application
The above named defendant(s) is/are jointly and severally liable and judgment shall be entered against
all defendants. The undersigned hereby certifies that the information contained herein is a true accounting of
the accrued arrearages due claimant pursuant to an Award of the Commission in this claim.
This the day of , 20 .
_____________________________________________
COMMISSIONER