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DocuSign Envelope ID: 716FBOE9-5CE9-44F5-9BAC-48D7E4C96CD6 <br /> UNCG <br /> Ce�tierF� <br /> N ICIV\Torch CaroRrlians <br /> claim by writing to the North Carolina Industrial Commission(4319 Mail Service Center, <br /> Raleigh,NC 27699-4319). The notice should include the member's name, address, social <br /> security number,the AmeriCorps Program's name and Service Site, and the date and nature of <br /> the injury. The member may provide all this information on a form(Form No. 18)provided by <br /> CorVel or the North Carolina Industrial Commission. <br /> More information about Workers' Compensation Disability and Benefits can be found at <br /> littp://Nveb.iincg.edti/li s/PolicyManivals/StaftManual/seetioti8/Nvorkers_coin. <br /> In the event of death resulting from an injury arising out of and in the course of service, compensation is <br /> paid to the surviving spouse for 400 weeks at 66-2/3 percent of the deceased member's average weekly <br /> wage at the time of the accident. If there is no surviving spouse, compensation payments due to a <br /> dependent child are paid for 400 weeks or until the child reaches the 18th birthday, whichever is later. <br /> The Workers Compensation Quick Reference Guide, UNCG HRS Form 301,UNCG HRS Form 19, and <br /> EE Statement form are located on the ACCESS and UNCG Human Resources websites." <br /> I can be reached at khouan.cmic(c uncg.edu or 336-256-1060 for additional information. <br /> Sincerely, <br /> Khouan Rodriguez <br /> Director <br /> ACCESS Project <br /> 19 CLlluraE DFrerHy,Ifrt3f <br /> 915 W.Lee St. Suite A,Greensboro,NC 27403 Phone(336)256-1060 Fax(336)334-5413 <br />