Establishing secure connection…Loading editor…Preparing document…

Form 28B 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!

North Carolina Industrial Commission - Form 28B
Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation

FILE VIA ELECTRONIC DOCUMENT FILING PORTAL: http://www.ic.nc.gov/docfilling.html

CONTACT INFORMATION: NCIC-CLAIMS ADMINISTRATION | TELEPHONE: (919) 807-2502 | HELPLINE: (800) 688-8349 | WEBSITE: HTTP://WWW.IC.NC.GOV

North Carolina Industrial Commission

Employee's Name

IC File #

Employer's Name

Emp. Code #

Telephone Number

Carrier Code

Address

Employer's Address

City

State

Zip

City

State

Zip

Insurance Carrier

Employer FEIN

Home Telephone

Work Telephone

Carrier's Address

Last 4 Digits of SSN

Sex

Date of Birth

Carrier's Telephone Number

Fax Number

1. Date of accident or disability from occupational disease

2. Salary was Total Dollar Amount

3. Number of weeks temporary total from , through $

from , through $

4. Number of weeks temporary partial from , through $

from , through $

5. Number of weeks permanent partial from , through $

6. Disfigurement amount paid $

7. Death benefits paid $

8. Loss of organ or body part benefits paid $

9. Total of lines 3 through 8, including any attorney fee paid to employee’s attorney $

10. Compromise Settlement Agreement amount $

11. a. Total medical paid $ Does this include final medical?

(Include bills for nursing, doctor, hospital, drugs, etc., but exclude rehabilitation and "medical only" paid)

b. Total rehabilitation paid $

c. Total “medical only” paid $

12. Total of lines 9, 10, 11a, and 11b. $

13. Miscellaneous payments:

Funeral benefits $

Second injury fund $

Hearing Costs $

Expert witness fees $

Other $

Total Miscellaneous Payments $

14. Has employee returned to work? If so, on what date? At what wage?

15. Date last compensation check forwarded Was this the final payment?

16. Date last medical compensation paid Was this the final payment?

Name of Employer or Carrier/Administrator

Title

Date

This form must be filed with the Industrial Commission at the address below, and a copy provided the employee with his last compensation check within 16 days following final payment of compensation and final medical payment.

FOR INDUSTRIAL COMMISSION USE ONLY

Days

Compensation Paid $

Medical $

IC Code

IMPORTANT NOTICE TO EMPLOYEE CLAIMING ADDITIONAL WEEKLY COMPENSATION CHECKS OR LUMP SUM PAYMENT

If you claim further compensation, you must notify the Industrial Commission in writing within two years from the date of receipt of your last compensation check or your rights to these benefits may be lost.

IMPORTANT NOTICE TO EMPLOYEE CLAIMING ADDITIONAL MEDICAL BENEFITS INJURED BEFORE JULY 5, 1994

If your injury occurred before July 5, 1994, you are entitled to medical compensation as long as it is reasonably necessary, related to your workers' compensation case, and authorized by the carrier or the Industrial Commission.

IMPORTANT NOTICE TO EMPLOYEE CLAIMING ADDITIONAL MEDICAL BENEFITS INJURED ON OR AFTER JULY 5, 1994

If your injury occurred on or after July 5, 1994, your right to future medical compensation will depend on several factors. Your right to payment of future medical compensation will terminate two years after your employer or carrier/administrator last pays any medical compensation or other compensation, whichever occurs last. If you think you will need future medical compensation, you must apply to the Industrial Commission in writing within two years, or your right to these benefits may be lost. To apply you may also use Industrial Commission Form 18M.

DEFINITION OF MEDICAL COMPENSATION

The term "medical compensation" means medical, surgical, hospital, nursing and rehabilitative services, and medicines, sick travel, and other treatment, including medical and surgical supplies, as may reasonably be required to effect a cure or give relief, and for such additional time, as in the judgment of the Industrial Commission, will tend to lessen the period of disability; and any original artificial members as may reasonably be necessary at the end of the healing period, and the replacement of such artificial members when reasonably necessitated by ordinary use or medical circumstances. N.C. Gen. Stat. § 97-2(19).

NEED ASSISTANCE?

If you have questions or need help and you do not have an attorney, you may contact the Industrial Commission’ Ombudsman at (800) 688-8349

Page 1 of 2

Form 28B - 02/2017

Additional Commission Use and Information from Page 2

The page 2 notices explain deadlines for additional weekly compensation checks or lump sum payment, the definition of medical compensation, and the employee assistance contact information.

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Form 28B North Carolina Industrial Commission is and when it’s used

Form 28B is a North Carolina Industrial Commission form commonly used in workers' compensation proceedings to transmit case-specific information between claimants, employers, medical providers, insurers, and the Commission. It typically documents factual or medical updates, proposed orders, settlement-related information, or administrative notices needed for case management. The form must be completed accurately to ensure proper routing, avoid processing delays, and preserve the claimant's statutory rights before the Commission.

Why accurate Form 28B completion matters

Completing Form 28B correctly ensures timely case processing, creates a clear administrative record, helps avoid procedural sanctions or delays, and protects the factual basis for medical or compensation decisions before the Commission.

Why accurate Form 28B completion matters

Who typically prepares and receives Form 28B

The form is completed and relied upon by multiple parties involved in a workers' compensation matter.

  • Claimants and representatives — Submit factual updates, medical documents, and settlement information to preserve claims and triggers.
  • Employers and insurers — Provide notices, admitted facts, or settlement terms required by the Commission.
  • Attorneys and medical providers — File expert reports, treatment summaries, or stipulations needed for hearings.

Each party should verify required fields, attachments, and signature authority before filing to avoid rejection or compliance issues.

Typical signers and preparers

Claims Administrator

A claims administrator prepares Form 28B when reporting employer responses, settlement offers, or administrative updates; they must verify policy details, claim numbers, and attach supporting medical records to ensure accurate Commission processing.

Workers' Comp Attorney

An attorney files Form 28B to submit legal positions, proposed orders, or stipulations; counsel should confirm signature authority, date formats, and whether notarization or witness statements are required under Commission rules.

Key procedural and security considerations

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
ESIGN/UETA: Electronic signatures enforceable under ESIGN/UETA
HIPAA: Use BAA when form includes PHI
Audit Trail: Capture IP, timestamp, and action log
Retention: Preserve records per regulatory schedule
RON/Notary: Use state-approved RON where allowed

Consequences of errors or missing information

Late Filing: May delay case scheduling
Missing Signature: Can void or return form
Incorrect Dates: May affect statute of limitations
Missing Attachments: Leads to incomplete record
HIPAA Breach: Potential regulatory exposure
Misidentification: Wrong party names cause rejection

Common mistakes to avoid when preparing Form 28B

  • Failing to include the correct claim or file number often causes the Commission to misroute the submission and delays case processing for weeks.
  • Using inconsistent party names across attachments or submitting documents with initials rather than the full legal name can create disputes over identity and service.
  • Omitting required medical records or failing to label attachments leads to incomplete evaluation and may force a refiling of the form.
  • Entering dates in ambiguous formats or omitting effective dates increases administrative burden and may affect deadlines or the record's legal effect.

Step-by-step: completing Form 28B

Follow these four practical steps to complete Form 28B accurately and reduce processing delays.

  • 01
    Gather documents: Collect claim number, medical reports, insurer details
  • 02
    Complete fields: Enter names, dates, and descriptions carefully
  • 03
    Attach evidence: Upload labeled records and provider reports
  • 04
    Sign & file: Execute signatures and submit per Commission rules

Typical filing workflow for Form 28B

A repeatable digital workflow helps maintain consistency and ensures every required step is recorded for the Commission.

  • Prepare: Create form with required fields and attachments
  • Assign: Route to signer(s) and confirm authority
  • Authenticate: Use email, SMS code, or stronger methods
  • Submit: File with Commission and retain certificate

Essential components of a professional Form 28B submission

A robust Form 28B package combines clear form fields, verifiable signatures, organized attachments, and an auditable submission record to satisfy Commission standards and opposing parties.

Clear identification

Include claimant, employer, insurer names, and Commission claim number on every page to avoid misrouting and to maintain a coherent administrative record across submissions and attachments.

Complete medical attachments

Attach labeled medical reports, dates of treatment, and provider contact information so the Commission and opposing parties can verify treatment history without follow-up requests.

Signature block

Provide printed name, title, date, and contact for every signer; indicate whether the signer is an attorney, adjuster, or medical professional and include authority to execute where applicable.

Notary or witness

When required by Commission rules or state law, include a notary block or witness lines and adhere to state notarization or witness-count requirements to ensure acceptance.

Audit trail

Preserve an execution certificate showing timestamps, IP addresses, and signer authentication to support validity under ESIGN and to respond to challenges about signature attribution.

Routing instructions

Specify how the form should be served and where the Commission should return correspondence; attach proof of service or certificate of mailing when required.

Suggested digital workflow settings for e-filing

Configure these settings when preparing Form 28B for electronic completion and submission to keep the process auditable and compliant.

Field Configuration
Authentication Email + SMS code or ID verification for sensitive filings
Field validation Require MM/DD/YYYY for dates; enforce numeric claim numbers
Attachments Limit types to PDF; require named files
Notifications Notify preparer and parties on completion

Technical and distribution considerations for e-submission

Choose a platform that supports PDF, Word, secure storage, and audit trails to preserve the Commission record.

  • File formats: PDF, DOCX, and TIFF supported
  • Integrations: Connect to Google Drive, NetSuite, Box
  • Authentication: SMS, email OTP, or SSO options

Ensure the chosen solution records signer attribution and retention metadata, supports required security standards, and can produce a downloadable certificate of completion for the Commission and all parties.

Timelines, expected processing, and response windows

Processing timelines depend on Commission workload and the nature of the filing; use expedited procedures only where expressly authorized by Commission rules.

Initial acknowledgment:

Commission typically issues an acknowledgement or docket number within business days

Service requirements:

Serve opposing parties when the Commission requires proof of service

Scheduling orders:

Expect a scheduling or hearing order after initial review

Deadline to respond:

Respond within timeframes set by Commission orders

Appeal windows:

Follow Commission rules for filing appeals and exceptions

Key milestones from preparation to Commission action

Track milestones to ensure timely filing, service, and preservation of rights at each step of the administrative process.

01

Prepare package

Assemble form, claim number, and labeled attachments

02

File with Commission

Submit completed form per Commission submission rules

03

Serve parties

Provide proof of service to opposing parties

04

Await scheduling

Receive acknowledgement and any scheduling or hearing order

Practical examples of Form 28B usage

These scenarios illustrate common ways the form supports case management and Commission communications.

Employer update

An employer files Form 28B to report a claimant's return-to-work status and attach last medical records

  • The form lists treatment dates and physician contact
  • Properly labeled attachments and accurate dates reduced follow-up requests and kept the hearing date on schedule.

Settlement notice

An insurer uses Form 28B to submit a proposed settlement and stipulation to the Commission

  • The packet includes settlement terms and release language
  • Including signed acceptance and proof of service streamlined approval and closed the claim without further administrative delay.

Comparing eSignature options for filing and executing Form 28B

Vendor pricing and feature availability vary; signNow appears first for comparison. Confirm plan-level features before selecting a solution for sensitive or regulated filings.

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 Yes, 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about Form 28B and e-submission

Answers to common questions about completing, signing, and filing Form 28B with the Commission, including eSignature and retention topics.


Need help? Contact support

Explore Templates

Copyright Cease and Desist Letter Bill of Sale and Agreement for Sale of Painting or Sculpture Application for License to Carry a Concealed Handgun Character Reference Letter for Court Judge Police Officer Applicant Interest Form Grant of Right to Use Photographic Likeness for Advertising Purposes
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.