Can I submit Form 24 electronically and e-sign it?

Yes. Electronic signatures are generally enforceable under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; however verify whether the North Carolina Industrial Commission accepts e-filed Form 24 and any required signer authentication before submitting an electronically signed Form 24.

Which fields commonly lead to rejection?

Clerks often reject incorrect or missing case numbers, mismatched party names, absent dates, unclear signatures, and missing supporting attachments. Double-check formatting (MM/DD/YYYY), exact legal names, and that required exhibits are attached to avoid returns or processing delays.

Does Form 24 require notarization or witnesses?

Typically Form 24 filings to the Industrial Commission do not require notarization or witness signatures. If you attach documents that themselves require notarization, follow the applicable notary rules for those documents before submission.

How should I attach supporting documents to Form 24?

Attach clear, legible copies of supporting exhibits in the order referenced on the form. Use searchable PDFs when possible, label exhibits sequentially, and ensure any medical records include HIPAA authorization if they contain protected health information.

What steps correct an incorrectly filed Form 24?

File an amended Form 24 or submit a corrective filing per Commission procedures and include a cover letter explaining the error. If deadlines were affected, request the clerk's guidance on motions to accept late or amended filings.

Are electronic signatures valid under federal and state law?

Yes. Electronic signatures are enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA in adopted jurisdictions when intent, consent, attribution, and record retention are satisfied. Retain an audit trail proving signer identity and consent.

Electronic Signature
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Form 24 North Carolina Industrial Commission

Form 24 North Carolina Industrial Commission

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Form No. 25D Revised 2/96

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE WORKERS' COMPENSATION ACT

NORTH CAROLINA INDUSTRIAL COMMISSION
RALEIGH

I.C. File No.

Emp. Code No.

Carrier Code No.

Carrier File No.

DENTISTS ITEMIZED STATEMENT OF CHARGE FOR TREATMENT

and

CERTIFICATION OF TREATMENT OF DISABILITY

The I.C. File No. is the unique identifier for this injury. It should be used on all future correspondence.

Code numbers assigned to each employer and carrier should be inserted before mailing.

Employee:

Employer:

Date of Accident:

Nature of Injury:

:31. Examination and treatment plan - List in order from tooth no, 1 through tooth no. :32 Use charting system shown.

LINGUAL

INDICATE MISSING TEETH WITH AN 'X'

Tooth # or letter	Surface	Description of service (including x-rays, prophylaxis, materials used, etc) Line No.	Date service performed Mo. Day Year	Procedure number	Fees	For administrative use only
					TOTAL

REMARKS FOR UNUSUAL SERVICES

All work must be fully detailed: Type of crowns, description of bridges, and design of partials. Including materials used. Please indicate on chart the work performed.

Please refer to N.C.I.C. medical fee schedule for C. P. T. codes for x-rays and surgery performed.

Injured requires further treatment as here described

As a result of examination made on , I hereby certify that disability resulting from the above injury has terminated, and I certify the injured able to return to work on

Has this accident resulted in any PERMANENT Disability?

PERMANENT Disability is as follows:

Describe any pre-existing disability (state extent).

General Remarks:

Date at

(Show Place and Date)

(Attending Dentist)

Identifying Number

Bill for Dental Services Must be Presented in Duplicate on This Form. Be Specific. No Other bill Services is Required. Give Full Explanation of Any Charges in Excess of Published Fee Schedule.

Please Submit Through Office of the Insurance. Carrier.

What the Form 24 North Carolina Industrial Commission Is

Form 24 is a claim-related form used by the North Carolina Industrial Commission to record certain filings in workers' compensation and related administrative matters. It standardizes claimant or employer submissions, captures case identifiers, party information, dates, and a brief statement of the filing purpose. Agencies and practitioners use it to open or update docketed matters, request hearings, or submit status reports tied to a workers' compensation claim. Using the correct Form 24 ensures case tracking, reduces clerical delays, and supports the Commission's administrative processing.

Why Accurate Form 24 Submissions Matter

Completing Form 24 correctly establishes a clear administrative record with the North Carolina Industrial Commission, helping preserve procedural rights, enable timely scheduling, and prevent avoidable delays or dismissals. Accurate entries improve case management, evidence linkage, and the speed of Commission responses.

Who Typically Prepares and Files Form 24

Claimants, employers, attorneys, and insurance adjusters use Form 24 to notify the Commission of filings and case events.

Claimants and claimant counsel tracking claim status, hearings, and administrative filings.
Employers and insurance carriers documenting payments, notices, or responses in claims files.
Commission clerks and administrative law judges relying on accurate form entries for docketing.

The form supports both parties and Commission staff by centralizing essential case identifiers and filing context for docketing and notices.

Required Core Data Elements on Form 24

Claimant Name: Full legal name as on ID.

Employer Name: Legal business or employer name.

Case Number: NCIC docket number if known.

Date of Filing: Use MM/DD/YYYY format.

Contact Information: Address, phone, and email.

Supporting Attachments: List and attach relevant documents.

Step-by-Step: Prepare, Sign, and Submit Form 24

Follow these steps to prepare, sign, and submit Form 24 to the North Carolina Industrial Commission.

01

Gather Documents: Collect claim number, correspondence, and supporting exhibits.
02

Complete Form: Fill all required fields and verify spelling and dates.
03

Sign: Sign physically or apply a compliant e-signature with retention.
04

Submit: File via Commission e-filing portal or mail per instructions.

How to Configure an Online Form 24 Workflow

Configure a digital workflow that mirrors the paper Form 24 fields to speed completion and maintain an audit trail.

Choose platform and file format	Use PDF or DOCX template supporting fillable fields.
Map fields and add validation rules	Add required markers, input masks, and conditional logic.
Select signer authentication and access controls	Enable email, SMS code, or advanced authentication as needed.
Enable audit trail and versioning	Record timestamps, IP, and document history automatically.
Configure delivery, reminders, and notifications	Set automated emails for pending signatures and confirmations.

Filing and Routing: What Happens After Submission

This flow describes where to file Form 24 and the typical routing inside the Commission.

Prepare: Complete form and attach supporting documents.
Authenticate: Verify signer identity per chosen method.
File: Submit via e-filing portal or mail to Commission.
Acknowledge: Receive confirmation and docket number from Commission.

Platform and Integration Requirements for Electronic Submission

Ensure your platform supports PDF, secure transmission (TLS), and preserves audit trails when submitting Form 24 electronically.

Formats: PDF and DOCX are supported formats.
Security: TLS in transit; AES-256 at rest.
Integrations: Works with NetSuite, MS 365, Google Workspace.

Key Deadlines and Timing to Watch

Key filing deadlines and response expectations for Form 24 submissions and related proceedings in North Carolina.

Guidance for initial filing timing:

Submit upon event triggering Commission jurisdiction.

Timeline for responses and objections:

Respond per Commission notice; typical short deadlines.

What to expect for hearing scheduling:

Scheduling depends on docket load; expect notice by mail or electronic service.

Retention and public access rules post-filing:

Documents remain part of the public docket unless sealed.

Consequences of filing after deadline:

May delay proceedings; could require motion for acceptance.

Milestones: From Filing to Hearing

Sequential milestones from submission through docketing and hearing for Form 24 matters.

01

Submission

Form received and assigned a docket number.

02

Administrative Review

Clerks verify completeness and route to assigned judge.

03

Notice Issued

Parties receive scheduling and hearing instructions.

04

Hearing or Disposition

Hearing held or matter administratively resolved.

Common Preparation Pitfalls to Avoid

Incomplete case numbers, mismatched party names, or missing dates which cause clerks to return or reject the filing and delay docketing.
Failing to attach required supporting documents, such as medical reports or notices, that substantiate the reason for filing Form 24.
Using handwritten or low-resolution scans that obscure signatures, dates, or text and complicate electronic processing and record retention.
Not confirming service methods or providing updated contact information, which can result in missed notices or improper service under Commission rules.

Consequences of Incorrect or Late Form 24 Filings

Dismissal Risk: Case may be administratively dismissed.

Missed Deadlines: Statutory appeal windows may lapse.

Evidence Exclusion: Untimely filings can bar exhibits.

Service Defects: Improper service undermines jurisdiction.

Privacy Exposure: Include PHI without authorization risks HIPAA violations.

Attorney Costs: Fixing errors increases legal fees.

Pricing and Feature Snapshot for eSignature Providers

Compare signNow pricing and baseline features against common eSignature vendors for Form 24 electronic signing and workflow needs.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

FAQs and Troubleshooting for Form 24

Answers to common questions about completing, signing, and submitting Form 24 to the North Carolina Industrial Commission.

Need help? Contact support

Can I submit Form 24 electronically and e-sign it?
Yes. Electronic signatures are generally enforceable under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; however verify whether the North Carolina Industrial Commission accepts e-filed Form 24 and any required signer authentication before submitting an electronically signed Form 24.
Which fields commonly lead to rejection?
Clerks often reject incorrect or missing case numbers, mismatched party names, absent dates, unclear signatures, and missing supporting attachments. Double-check formatting (MM/DD/YYYY), exact legal names, and that required exhibits are attached to avoid returns or processing delays.
Does Form 24 require notarization or witnesses?
Typically Form 24 filings to the Industrial Commission do not require notarization or witness signatures. If you attach documents that themselves require notarization, follow the applicable notary rules for those documents before submission.
How should I attach supporting documents to Form 24?
Attach clear, legible copies of supporting exhibits in the order referenced on the form. Use searchable PDFs when possible, label exhibits sequentially, and ensure any medical records include HIPAA authorization if they contain protected health information.
What steps correct an incorrectly filed Form 24?
File an amended Form 24 or submit a corrective filing per Commission procedures and include a cover letter explaining the error. If deadlines were affected, request the clerk's guidance on motions to accept late or amended filings.
Are electronic signatures valid under federal and state law?
Yes. Electronic signatures are enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA in adopted jurisdictions when intent, consent, attribution, and record retention are satisfied. Retain an audit trail proving signer identity and consent.

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