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.

Form 18B is titled Claim by Employee, Representative or Dependent for Benefits for Lung Disease. This form is to be filled if an employee has been diagnosed with lung disease that was caused by employment and wants benefits for it.  In this case, lung disease includes asbestosis, silicosis and byssinosis. They must include the date of diagnosis, provide the doctor who made the diagnosis and attach all pertinent medical records for the diagnosis. This is similar to a traditional Form 18 but, instead, is intended only for the purposes of cases resulting in lung disease.

The employee must disclose the place of employment that they were working at that pertains to the diagnosis of the lung disease. They must also include their employment history for every job where exposure may have occurred so that the Industrial Commission can check into each of them. It is important in cases like this that the place of employment that caused the lung disease be properly determined because they will be the ones issuing the benefits to the employee.

The employee must also disclose the name and address of every doctor and/or hospital that they had been treated in for the 20 years prior to the diagnosis. They must also put for what purpose they were treated if they know. Signing this form gives any of those doctors and hospitals to release any medical records to parties that are reviewing their workers compensation claim. It is very important that this form is filed out correctly so that anyone reviewing the claim knows which physicians they need to be in contact with.

As with all other forms dealing with a worker’s compensation claim, the original of this form must be returned to the Industrial Commission. A copy of the signed form should be furnished to their employer and they employee should of course keep a copy of the completed form for their records.