North Carolina Workers’ Compensation Forms
When making a workers’ compensation claim, the forms are extremely important, as well as the deadlines for filing the forms. Some of the most important forms you may need to be familiar with are:
Form 19 - This is the Report of Injury form to be completed by your employer.
Form 18 - This is the Injured Worker Notice of Accident Claim form to be completed and filed with the Industrial Commission by you when you have been injured on the job.
Form 18B - This is a claim form for several occupational diseases, including lung disease asbestosis, silicosis and byssinosis.
Form 33 - This is the Request that Claim Be Assigned for Hearing. This form can be filed to request a hearing if you have a dispute with your employer concerning your medical care or other issues. This form can also be filed if you are not receiving all, or some, of the benefits to which you are entitled.
Form 25P - This is a form to List an Itemized Statement of Charges for Prescription Drugs. The employee can use this form to obtain reimbursements for prescriptions.
Form 25T - This is a form to List an Itemized Statement of Charges for Travel. Employees are entitled to reimbursement for mileage if the employee travels 20 miles or more round trip for medical treatment.
Form 24 - This is an Application to Terminate or Suspend Payment of Compensation. An employer may file this form if it is paying workers’ compensation benefits and seeks to terminate these benefits. If an employee is receiving compensation and disagrees that benefits should be stopped, it is very important for an employee to timely respond to the Form 24 request.
Form 28C - Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid Pursuant to a Compromise Settlement Agreement.
Form MSC2 - This is a Petition for Order Referring Case to Mediated Settlement Conference.
Form MSC4 - This is a form for the designation of a workers’ compensation mediator.
Form MSC8 - This is a “Mediated Settlement Agreement” a workers’ compensation mediator will use to report to the Industrial Commission if your case settles at mediation.
These forms may be downloaded and printed by clicking the form name links above. They can also be found on the North Carolina Industrial Commission website.
Workers’ Compensation Lawyer Help With Your Claim
If you have trouble completing any of these workers’ compensation forms, contact the North Carolina workers’ compensation lawyers at the law firm of Hemmings & Stevens, PLLC today. We offer free consultations and work on a contingent fee basis, which means there are no fees unless we make a recovery for you. For assistance, call us at 919.277.0161 or contact us online.