Michael F. Easley, Governor
Pamela T. Young, Chair

Stephen T. Gheen
Chief Deputy Commissioner
Office: (919) 807-2540
Home: (919) 384-1292

Bernadine S. Ballance, Commissioner
Buck Lattimore, Commissioner
Laura K. Mavretic, Commissioner
Danny L. McDonald, Commissioner
Christopher Scott, Commissioner
Dianne C. Sellers, Commissioner

North Carolina
Industrial Commission



All Interested Parties


Chief Deputy Commissioner Stephen T. Gheen


October 19, 2007

RE: January 2008 Tentative Special Docket/Advisory

Special Notice
This Advisory Contains Special Instructions & A Special Listing of New Cases
Please Read Carefully

Form 53 Cases

The Claims Administration Section has referred 120 “Form 53” cases to the Deputy Section for Docketing in January 2008.

“Form 53” cases are those in which Form 21 ‘s or Form 26’s were filed with the Industrial Commission. The Claims Administration Section returned a “Form 53” to the insurance carrier/third party administrator requesting clarification of the Form 21/26 application or additional information. A response sufficient to approve the agreement was not received.

The Claims Administration Section made repeated attempts to communicate with the carrier/third party administrator to solicit a response to approve the Form 21/26 agreement. In those cases in which no communication was received, the Claims Administration Director subsequently issued an Order mandating a response to the “Form 53” within a specified period or the case would be referred to the Deputy Commissioner Section to make a formal judicial inquiry.

The 120 cases are in a special file Form 53/Insurance Carrier and listed by I.C. File Number, Alphabetically by Plaintiff, and Alphabetically by Carrier. All cases in this file are “Form 53” referrals listed by insurance carrier/third party administrator alphabetical order.

An insurance carrier/third party administrator may negate the necessity of docketing these cases by providing the information requested in the Form 53 issued by the Claims Administration Section prior to November 9, 2007.

All responses to “Form 53” cases and all inquiries related thereto should be directed to the Claims Examiner listed on the spreadsheet. The contact information for each claims examiner is listed below:

Mae Alexander


(919) 807-2502

Paula J. Barnes


(919) 807-2502

Diana Fields


(919) 807-2502

Rose Frazier


(919) 807-2502

Brad Honeycutt


(919) 807-2506

Maggie White


(919) 807-2506

Communication by e-mail is preferred, but not required. Do not direct inquiries to the Deputy Commissioner Section for “Form 53” cases. The Claims Examiner is the individual who can authorize a “Form 53” case removed from the docketing process until an actual docket is published.

As per the Rules of the North Carolina Industrial Commission, a hearing cost will be assessed in every case that is docketed.

N.C. Industrial Commission ·   4340 Mail Service Center ·   Raleigh, NC 27699-4340
Main Telephone: (919) 807-2500 ·   Fax: (919) 715-0282
NCIC Home Page: http://www.ic.nc.gov/