Workers' Compensation Rules
of the N.C. Industrial Commission

Revisions Effective 1 January 2011


ARTICLE IV. DISABILITY, COMPENSATION, FEES

Rule 409
Claims for Death Benefits

  1. Report of Fatalities
     
    1. Any person claiming entitlement to death benefits under the Act shall give written notice to the employer of the occurrence of death allegedly arising out of and in the course of employment in accordance with N.C. Gen. Stat. 97-22.
       
    2. An employer shall notify the Commission of the occurrence of a death resulting from an injury or occupational disease allegedly arising out of and in the course of employment by timely filing a Form 19 within five days of knowledge thereof. In addition, an employer or carrier/administrator shall file with the Industrial Commission a Form 29, "Supplementary Report for Fatal Accidents," within 45 days of knowledge of a death or allegation of death resulting from an injury or occupational disease arising out of and in the course of employment.
       
  2. Identifying Beneficiaries
     
    1. An employer or carrier/administrator shall make a good faith effort to discover the names and addresses of decedent’s beneficiaries under N.C. Gen. Stat. 97-38 and identify them on the Form 29.
       
    2. In all cases involving minors or incompetents who are potential beneficiaries, a guardian ad litem shall be appointed pursuant to Rule 604.
       
    3. If an issue exists as to whether a person is a beneficiary under N.C. Gen. Stat. 97-38, the employer or carrier/administrator and/or any person asserting a claim for benefits may file a Form 33 Request for Hearing for a determination by a Deputy Commissioner.
       
  3. Liability Accepted by Employer
     
    1. If the employer or carrier/administrator accepts liability for a claim involving an employee’s death and there are no apparent issues necessitating a hearing for determination of beneficiaries and/or their respective rights, the parties shall submit an Agreement for Compensation for Death executed by all interested parties or their representatives on Industrial Commission Form 30. All agreements must be submitted to the Industrial Commission on a Form 30 as set forth in Rule 501(4), (5) and (6).
       
    2. Said agreement shall be submitted along with all relevant supporting documents, including death certificate of the employee, any relevant marriage certificate and birth certificates for any dependents.
       
  4. Liability Denied by Employer
     
    1. If the employer or carrier/administrator denies liability for a claim involving an employee’s death, the employer or carrier/administrator shall send a letter of denial to all potential beneficiaries, their attorneys of record, if any, all heath care providers that have submitted bills to the employer or carrier/administrator, and the Industrial Commission. The denial letter shall specifically state the reasons for the denial and shall further advise of a right to hearing.
       
    2. Any potential beneficiary or the employer or carrier/administrator may request a hearing as provided in Rule 602.
       
  5. Payment of Death Benefits
     
    1. Upon approval of the Industrial Commission of a Form 30, Agreement for Compensation for Death, or the issuance of a final order of the Industrial Commission directing payment of death benefits pursuant to N.C. Gen. Stat. 97-38, payment may be made by the employer or carrier/administrator directly to the beneficiaries, with the following exceptions: (1) any applicable award of attorney fees shall be paid directly to the attorney; and (2) benefits due to a minor or incompetent.
       
    2. (i) Subject to the discretion of the Industrial Commission, any benefits due to a minor pursuant to N.C. Gen. Stat. 97-38 may be paid directly to the parent as natural guardian of the minor for the use and benefit of the minor if the minor remains in the physical custody of the parent as natural guardian. If the minor is not in the physical custody of the parent as natural guardian, the Industrial Commission may order that payment be made through some other proper person appointed by a court of competent jurisdiction.
       

      (ii) In order to protect the interests of an incompetent beneficiary, the Industrial Commission in its discretion may order that benefits be paid to the beneficiary’s duly appointed general guardian for the beneficiary’s exclusive use and benefit, or to the Clerk of Court in the county in which he resides for the beneficiary’s exclusive use and benefit as determined by the Clerk of Court.

      (iii) Upon a change in circumstances, any interested party may request that the Industrial Commission amend the terms of any award with respect to a minor or incompetent to direct payment to another party on behalf of the minor or incompetent. When a beneficiary reaches the age of 18, any remaining benefits shall be paid directly to the beneficiary.
       

    3. In the case of commuted benefits, only those sums which have not accrued at the time of the entry of the Order are subject to commutation.
       
  6. Procedure for Award of Death Benefits Based on Stipulated Facts
     
    1. Where the parties seek a written opinion and award from the Commission regarding the payment of death benefits in uncontested cases in lieu of presenting testimony at a hearing before a Deputy Commissioner, the parties may make application to the Commission for a written opinion by filing a written request with the Dockets Director.
       
    2. The parties shall file the following information, along with a proposed Opinion and Award or Order filed electronically, by joint stipulation, affidavit or certified document:
       
      1. a stipulation regarding all jurisdictional matters;
         
      2. the decedent’s name, social security number, employer, insurance carrier or servicing agent, and the date of the injury giving rise to this claim;
         
      3. a Form 22 or stipulation as to average weekly wage;
         
      4. any affidavits regarding dependents;
         
      5. the death certificate;
         
      6. I.C. Form 29;
         
      7. Guardian ad Litem forms, if any beneficiary is a minor or incompetent;
         
      8. proof of beneficiary status, such as marriage license, birth certificate, or divorce decree;
         
      9. medical records, if any;
         
      10. a statement of payment of medical expenses incurred, if any; and
         
      11. a funeral bill or stipulation as to payment of the funeral benefit.
         
    3. Upon receipt of said information and notice to potential beneficiaries, the Deputy Commissioner shall render a written Opinion and Award.
        
  7. Any attorney seeking fees for the representation of an uncontested claim shall file an affidavit or itemized statement in support of an award of attorney fees.

Go to Workers' Compensation Rules Page


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/