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North Carolina Form Center -

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Form

Description

form19.pdf Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission
form29.pdf Supplemental Report for Fatal Accidents
form18.pdf Notice of Accident to Employer and Claim of Employee, Representative, or Dependent
forma18.pdf Notice of Accident to Employer and Claim of Employee, Representative, or Dependent (Spanish)
form18b.pdf Claim by Employee, Representative, or Dependent for Lung Disease, Including Asbestosis, Silicosis, and Byssinosis
form18m.pdf Employee's Application for Additional Medical Compensation(Applicable to Injuries by Accident or Occupational Illness on or After July 5, 1994)
form21.pdf Agreement for Compensation for Disability
form21s.pdf Agreement for Compensation for Disability (Spanish)
form22.pdf Statement of Days Worked and Earnings of Injured Employee
form23.pdf Application to Reinstate Payment of Disability Compensation
form24.pdf Application to Terminate or Suspend Payment of Compensation
form25c.pdf Authorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment
form25cs.pdf Authorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment (Spanish)
form25n.pdf Notice to the Commission of Assignment of Rehabilitation Professional
form25p.pdf Itemized Statement of Charges for Drugs
form25pr.pdf Request for Preauthorization of Medical Treatment
form25r.pdf Evaluation for Permanent Impairment
form25t.pdf Itemized Statement of Charges for Travel
form26.pdf Supplemental Agreement as to Payment of Compensation
form26a.pdf Employers Admission of Employee's Right to Permanent Partial Disability
form26d.pdf Agreement for Payment of Unpaid Compensation in Unrelated Death Cases
form26i.pdf Medical Provider Dispute Resolution Questionnaire
form28.pdf Return to Work Report
form28b.pdf Report of Employer or Carrier / Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation
form28c.pdf Report of Employer or Carrier / Administrator of Compensation and Medical Compensation Paid Pursuant to a Compromise Settlement Agreement
form28t.pdf Notice of Termination of Compensation by Reason of Trial Return to Work
form28u.pdf Employee's Request that Compensation be Reinstated After Unsuccessful Trial Return to Work
form30.pdf Agreement for Compensation for Death
form30a.pdf Notice of Award
form30d.pdf Award Approving Agreement for Compensation for Death
form31.pdf Application for Lump Sum Award
form33.pdf Request that Claim be Assigned for Hearing
form33s.pdf Request that Claim be Assigned for Hearing (Spanish)
form33i.pdf Intervenor's Request that Claim be Assigned for Hearing
form33Ifeeform.pdf Certification of Payment of Processing Fee for the Form 33I
form33r.pdf Response to Request that Claim be Assigned for Hearing
form36.pdf Subpoena for Witness
form42.pdf Application for Appointment of Guardian Ad Litem
form44.pdf Application for Review
form51.pdf Annual Consolidated Fiscal Report of "Medical Only" or "Lost Time" Cases
form51in.pdf Instructions for filling out Form 51
form60.pdf Employer's Admission of Employee's Right to Compensation
form61.pdf Denial of Workers' Compensation Claim
form62.pdf Notice of Reinstatement or Modification of Compensation
form63.pdf Notice to Employee of Payment of Compensation Without Prejudice or Payment of Medical Benefits Only Without Prejudice
form87a.pdf Affidavit of Accrued Arrearages
form87c.pdf Certificate of Accrued Arrearages or Certified Accounting of Award
form87s.pdf Statement of Accrued Arrearages
form90.pdf Report of Earnings
frmec100.pdf Erroneous Conviction - Claimant's Petition for Compensation
msc1.pdf Consent Order for Mediated Settlement Conference
msc2.pdf Petition for Order Referring Case to Mediated Settlement Conference
msc3.pdf Order for Mediated Settlement Conference
msc4.pdf Designation of Mediator
msc5.pdf Report of Mediator
msc6.pdf Mediator's Declaration of Interest and Qualifications
msc7.pdf Report of Evaluator
msc8.pdf Mediated Settlement Agreement
msc9.pdf Mediated Settlement Agreement - Alternative Form
formt-1.pdf Claim for Damages under Tort Claims Act
formt-3.pdf Release of Tort Claim
formt-44.pdf Application for Review
csachecklist.pdf Health Benefit Plans and Medical Costs Internal Checklist for the Review of Compromise Settlement Agreements
cert_pay.pdf Certification of Payment of Processing Fee for Compromise Settlement Agreements
indigentappeal.pdf Petition to Appeal as an Indigent Person
indigentsue.pdf Petition to Sue as an Indigent Person
nurseref.pdf Workers' Compensation Nurses Section Referral Form
deathben.pdf Claim for Benefits Under the Law Enforcement Officers', Firemen's, Rescue Squad Workers' and Civil Air Patrol Members' Death Benefits Act
wcmsques.pdf Workers' Compensation Medical Status Questionnaire
EFT_authorization.pdf Manage AR EFT Payment Account Set-Up Form (added 4/11)
form17.pdf POSTER - N.C. Workers' Compensation Notice to Injured Workers and Employers
form17s.pdf POSTER - N.C. Workers' Compensation Notice to Injured Workers and Employers (Spanish)