Form 19 North Carolina Industrial Commission

Employee's Name

Employer's Name

Telephone Number

Address

Employer's Address

City

State

Zip

Insurance Carrier

Policy Number

( ) Home Telephone

( ) Work Telephone

Carrier's Address

City

State

Zip

Social Security Number

M F Sex

Date of Birth

Carrier's Telephone Number

Carrier's Fax Number

described as follows: on at

Describe the injury or occupational disease,

Time of Injury Date (required)

City and County

Occupation when injured:

Nature of employer's business:

Medical treatment received? Yes No

Number of hours worked per day:

Weekly wage: $

Days worked per week:

Signature of (Check One) Employee, Attorney,
Representative, or Dependent

Printed Name of Signer

E-mail Address

( ) Telephone Number

Address

City

State

Zip Code

Date Completed

GENERAL INFORMATION ON THE FORM 18

1. What does a Form 18 do?

A Form 18 establishes a legal claim of injury on your behalf if filed within two years of the date of injury or occupational disease, and gives the required written notice to the employer if a copy is submitted to the employer within 30 days of the injury. The employer is required by law to file a Form 19 if the employee misses more than one day of work due to the injury or if the medical bills exceed $2,000.00. However, the employer's filing of a Form 19 does not satisfy the employee's obligation to file a claim. In order to ensure the employee's rights are protected, the employee must file a Form 18 even though the employer may be paying compensation or the Industrial Commission may have opened a file for the injury.

2. To whom should the Form 18 be sent?

The original Form 18 should be submitted to the Industrial Commission. The injured worker should keep one copy for his or her records and one copy should be submitted to the employer at the time of the injury.

3. What numbers do I write in the upper right corner?

You do not need to fill in the spaces on the upper right corner of the Form 18. If you know that your employer has already filed a report of injury, (Form 19) and you know what your I.C. (Industrial Commission), File Number is, you may write the number in the “I.C. File No." space. If you do not already have an I.C. File Number, the Industrial Commission will assign one upon receipt of the Form 18. The other three spaces, “Emp. Code No.,” “Carrier Code No.," and "Employer FEIN" are for internal use only.

4. What if I do not know who my employer's insurance carrier is?

If you do not know who the employer's insurance carrier is you may either ask your employer for the information, call the Industrial Commission's Claims Administration Section at (800) 688-8349 then press “1” after the prompt, or simply leave the line blank.

5. When listing the number of days out of work, do I count partial days?

Yes, you include partial as well as whole calendar days not worked. However, the days do not need to be consecutive.

6. What happens after I file the Form 18?

The Industrial Commission will mail an acknowledgement letter to you after your Form 18 is processed. Processing time varies according to current workload. The Industrial Commission will mail a copy of the acknowledgement letter to the employer or its workers' compensation insurance carrier asking them to contact you and inform you if compensation will be paid to you voluntarily.