North Carolina Workers' Compensation Calculation Program

ORDER AND RENEWAL FORM

To order NCCompOnline, please fill out the form below (all fields are required) and choose one of the following:

Print, and mail this form with a check or credit card information to:

Kim K. Steffan, Attorney at Law
2411 Old NC 86
Hillsborough, NC 27278

OR:

Fax the printed form with credit card information to: 919-732-7304

Customer Details:
First Name
Last Name
Middle Initial
Title
Organization
Work Phone
Fax
Email
Product Details:
Qty	Description
	Annual subscription (Jan. 1 - Dec. 31) for NCComp (new or renewal), up to 3 user accounts ($89.00 + $6.68 tax = $95.68 total)
	Subscription for each additional block of 3 users, also annually ($35.00 + $2.63 = $37.63 total)
Payment Details:
Credit Card
Cardholder Name
Card Number
Expiration Date
Card Verification Code	(usually 3 digits)
Billing Address
Billing Address (more)
City
State
Zip
After we receive your order form and payment, our NCComp Administrator will contact your firm to create usernames and passwords for all your user accounts.

Customer Details:

First Name

Last Name

Middle Initial

Title

Organization

Work Phone

Fax

Product Details:

Qty

Description

Annual subscription (Jan. 1 - Dec. 31) for NCComp (new or renewal), up to 3 user accounts
($89.00 + $6.68 tax = $95.68 total)

Subscription for each additional block of 3 users, also annually
($35.00 + $2.63 = $37.63 total)

Payment Details:

Credit Card

Cardholder Name

Card Number

Expiration Date

Card Verification Code

(usually 3 digits)

Billing Address

Billing Address (more)

City

State

Zip

After we receive your order form and payment, our NCComp Administrator will contact your firm to create usernames and passwords for all your user accounts.