Form 61 2026

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The document is a denial notice for a workers' compensation claim issued by the North Carolina Industrial Commission. It informs the employee or their dependents that their claim for an injury or occupational disease has been denied, outlines the requirement for the employer or insurance carrier to provide reasons for the denial, and explains the employee's right to request a hearing if they disagree with the decision.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the IC File Number, Employee Code, and Carrier Code at the top of the form. These identifiers are crucial for tracking your claim.
Fill in the employee’s name, employer’s name, and their respective addresses. Ensure accuracy as this information is vital for communication.
Next, provide details about the insurance carrier including the policy number and contact information. This helps in processing claims efficiently.
Indicate the date of injury or occupational disease clearly. This date is essential for determining eligibility.
In the section addressing denial reasons, ensure that a detailed explanation is provided. This is important for both parties involved.
Finally, have the employer or carrier/administrator sign and date the form before submission to ensure its validity.

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