Every workers’ compensation case in North Carolina will involve several NC Workers’ Compensation Forms issued by the North Carolina Industrial Commission. There is just no way around it. But be very careful using, or not using, these workers’ comp forms. Improperly completing a NC workers’ compensation form, or failing to timely submit a form, might damage or even end your NC workers’ comp case.
Most NC workers’ comp cases begin with the injured worker filing a Form 18 Notice of Accident. It is important that the injured worker properly and timely file notice of his or her NC workers’ compensation claim. The Form 18 should be filed with the NC Industrial Commission, with a copy to the employer. It is also a good idea to send a copy of the Form 18 to the employer’s workers’ compensation insurance company. In most circumstances the employer or their insurance company should file a Form 19 when they become aware of a workers’ comp claim in NC.
Workers’ Comp Cases in NC should be accepted by Form 60 or Form 63, or denied by Form 61. If the employer has not formally accepted the claim by Form 60 you may be looking at problems down the road.
A Form 18M is used to keep medical treatment open beyond two years from the last payment of benefits. NC workers’ compensation forms are also used under NC workers’ compensation law for permanent disability ratings, travel expenses, to request a hearing, to terminate disability payments, to resume disability payments, to show a payment was made, and for just about everything else.
The NC workers’ compensation forms are available on the North Carolina Industrial Commission’s website. But be careful filling out these forms. A NC workers’ compensation claim can be lost when a form is filled out incorrectly or is not properly submitted.
If you have a question about NC workers’ compensation forms please call or email for a free consultation with a Board Certified Specialist in NC Workers’ Compensation Law. NC workers’ comp lawyer Kevin Bunn has been representing injured workers’ before the North Carolina Industrial Commission for over 20 years. Let him help guide you through the maze of forms related to your NC workers’ comp case.
This is a list of the forms injured workers will see most often:
- Form 18 — Notice of Accident With Instructions
- Form 18M — Request for Additional Medical Compensation
- Form 19 — Employer’s Report of Injury to the NCIC
- Form 21 — Agreement for Compensation for Disability
- Form 22 — Statement of Days Worked & Earnings of Employee
- Form 23 — Application to Reinstate Payment of Disability Compensation
- Form 24 — Application to Stop or Suspend Pmt. of Compensation
- Form 25C — Authorization for Rehab Professional to Obtain Medical Records of Current Treatment
- Form 25N — Notice of Assignment of Rehabilitation Professional
- Form 25R — Evaluation for Permanent Impairment
- Form 25T– Itemized Statement of Travel Charges
- Form 26 — Supplemental Agreement as to Payment of Compensation
- Form 26A — Employer’s Admission of Employee’s Right to Permanent Partial Disability
- Form 26D — Agreement for Payment of Unpaid Compensation in Unrelated Death Cases
- Form 28 — Return To Work Report
- Form 28B — Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation
- Form 28C — Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid Pursuant to a Compromise Settlement Agreement
- Form 28T — Notice of Termination of Compensation by Reason of Trial Return to Work
- Form 28U — Employee’s Request That Compensation Be Reinstated After Unsuccessful Trial Return to Work
- Form 29 — Supplemental Report to Form 19 for Fatal Accidents
- Form 30 — Agreement for Compensation for Death
- Form 30A — Notice of Award
- Form 30D — Award Approving Agreement for Compensation for Death
- Form 31 — Application for Lump Sum Award
- Form 33 — Request That Claim Be Assigned for Hearing
- Form 33R — Response to Request That Claim Be Assigned for Hearing
- Form 36 — Subpoena for Witness
- Form 42 — Application for Appointment of Guardian Ad Litem
- Form 44 — Application for Review
- Form 60 — Employer’s Admission of Employee’s Right to Compensation
- Form 61 — Denial of Workers’ Compensation Claim
- Form 62 Notice of Reinstatement or Modification of Compensation
- Form 63 — Notice to Employee of Payment of Compensation Without Prejudice or Payment of Medical Compensation Without Prejudice
- Form 90 Report of Earnings
- Form MSC3 Order for Mediated Settlement Conference
- Form MSC4 Designation of Mediator
- Form MSC5 Report of Mediator
- Form MSC8 Mediated Settlement Agreement
- Form T-44 Application for Review