Fill and Sign the Form 19 Nc Industrial Commission Ncgov

FORM 18 03/2018 P AGE 1 OF 1 F OR IC U SE ONLY R ESEARCHER : ______ CC: _____________ EC: _____________ D ATA ENTRY : ______ F ORM 18 A TTORNEYS : F ILE WITH AN IC F ILE NUMBER VIA EDFP HTTP ://WWW .IC .NC .GOV /DOCFILING .HTML OR I F NO IC FILE NUMBER , FOLLOW EMPLOYEE FILING OPTIONS . E MPLOYEES : E -MAIL TO : FORMS @IC.NC .GOV OR MAIL TO : NCIC - C LAIMS SECTION 1235 M AIL SERVICE CENTER R ALEIGH, NC 27699-1235 M AIN TELEPHONE : (919) 807-2500 H ELPLINE : (800) 688-8349 W EBSITE : HTTP ://WWW .IC .NC .GOV / North Carolina Industrial Commission IC File # N OTICE OF ACCIDENT TO EMPLOYER AND CLAIM OF Emp. Code # E MPLOYEE , R EPRESENTATIVE , OR DEPENDENT Carrier Code # (G.S. §§97-22 THROUGH 24) Employer FEIN The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence. The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act () - Employee’s Name Employer's Name Telephone Number Address Employer’s Address City State Zip City State Zip Insurance Carrier Policy Number ( ) - ( ) - Home Telephone Work TelephoneCarrier’s Address City State Zip - - M F / / ( ) - ( ) - Social Security Number Sex Date of Birth Carrier’s Telephone Number Carrier’s Fax Number EMPLOYEE – This form must be filed with the Industrial Commission within two years of the date of injury o r occupational disease or your claim may be barred. Notice shall be given to the employer immediately after the accident or as soon as practicable and within 30 days. (This form should also be used for occupational disease claims; however, for asbestosis, silicosis and b yssinosis, Form 18B is to be used. ) Notice is hereb y given, as required b y law, that the above-named emplo yee sustained an in jury or contracted an occupational disease, described as follows: on / / at .Describe the injury or occupational disease, Time of Injury Date (required) City and County includin g the specific bod y part involved (e.g., ri ght hand, left hand ) Describe how the injury or occupational disease occurred: Occupation when injured: Nature of employer’s business: Number of da ys out of work due to in jury: Medical treatment received? Yes No Weekl y wa ge: $ Number of hours worked per da y: Da ys worked per week: NOTE: If employee is unable to sign this form, another may sign for him. This form should be typed or printed by hand in black ink, if possible. Empl oyee should retain one signed copy of this notice, mail one signed copy to the Industrial Commission at the address below, and provide one si gned cop y to emplo yer. ( ) - 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 EMPLOYER: This notice is being sent to you in compliance with requirements of the North Carolina Workers’ Compensation Act, in order that the medical services pres cribed by the Act may be obtained; and, if disability extends be yond 7 da ys duration, or if death ensues, compensation ma y be paid accordin g to law. 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 th e 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 lette r 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 in surance carrier asking them to contact you and inform you if compensation will be paid to you voluntarily.