What Is A Form 30 In A North Carolina Workers Compensation Case?

Form 30 is an Agreement for Compensation for Death. This form is used when an employee passes away because of an accident at work and his or her dependents or next of kin are petitioning for compensation for the deceased. Each dependent or next of kin, the plaintiff’s attorney, employer and insurance carrier or administrator must agree to the information provided and all of their signatures are required on this form. All parties must agree the employer and deceased employee were bound by provisions of the North Carolina Workers’ Compensation Act.

The date of the employee’s accident and the date of their death must be included, along with the average weekly wage of the employee and their weekly compensation rate. All the dependents or next of kin who are entitled to receive compensation must be listed on this form. If they are not listed on the form they may not receive future compensation. They must provide their name, address, date of birth, age, relationship and indicate if they are a whole or partial dependent or next of kin to the deceased.

The employer and carrier must then state the weekly rate they are going to pay the dependents or next of kin and how long they will pay it for. Depending on if the dependents or next of kin are a widow/widower, widow/widower with minor children, minor children only, whole dependent other than widow/widower or minor children or partial dependent will determine how long and the amount that they would receive.  Everyone except the partial dependent will receive the weekly rate that was previously listed and the partial dependent will receive the weekly rate multiplied by the percentage of support provided by the deceased.

All parties must also agree that the widow/widower was or was not able to support themselves after the death because of physical or mental disability and if they will or will not continue to receive benefits during their lifetime or until remarriage.  The employer and its carrier also agree to pay burial expenses and must list the amount they are agreeing to pay.

A Form 30 must be submitted to the Industrial Commission along with a completed Form 30D Award Approving Compensation for Death. Several other documents, if appropriate, must also be submitted to the Commission along with the completed Form 30. These documents are the death certificate, marriage certificate, divorce decree, birth certificate if a minor, Form 42 Application for Appointment of Guardian Ad Litem and Form 29 Supplemental Report for Fatal Accidents.

If a loved one has been killed in a workplace accident it is critical you speak with a qualified workers’ compensation attorney before signing any documents. At Duncan Law we offer a free, no strings attached, consultation where we can sit down with you and other loved ones and discuss which route will ensure you and your family maximize the amount of compensation you can recover.