Who must sign the form?

The injured worker should sign to certify facts; employers typically complete employer-specific fields and the insurer or adjuster may acknowledge receipt. Signatures create attribution evidence under the ESIGN Act (15 U.S.C. ch. 96) and state electronic transaction law where applicable.

Can the form be signed electronically?

Yes. Electronic signatures meeting ESIGN and UETA standards are generally valid for workers' compensation documents. Ensure intent, consent, signer attribution, and retention/reproducibility are captured per the four-part ESIGN legal validity test.

What if I need to correct an error?

Do not alter a signed copy. Prepare an amended form or written correction, have the responsible parties sign and date it, and submit both the original and the correction to the insurer to preserve auditability.

Where do I submit the completed form?

Provide the completed form to your employer and the employer should submit it to the insurer or third-party administrator. File with the North Carolina Industrial Commission only if required for hearings or contested claims.

How long must I keep claim documents?

Retain claim files for the active claim plus statutory periods. Follow federal standards for related payroll/tax records (IRS: 3 years, IRC §6501(a)) and health records for six years under HIPAA (45 CFR §164.530(j)).

Are notarization or witnesses required?

Notarization and witness requirements are uncommon for initial workers' compensation claim forms but vary by state and document type; consult the state Industrial Commission or legal counsel if a sworn affidavit or hearing exhibit is involved.

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NC Workers' Compensation Form

NC Workers' Compensation Form

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NORTH CAROLINA INDUSTRIAL COMMISSION

RALEIGH, NORTH CAROLINA

RELEASE OF TORT CLAIM UNDER GENERAL STATUTES 143-291 et seq.

I. C. File No. T-

KNOW ALL MEN BY THESE PRESENTS, That I, We, for the sole consideration of dollars to be paid by

(Defendant)

the payment whereof being made under the provision of General Statutes 143-291 et seq., I, We, have released, and discharged and by these presents do for myself, ourselves, my, our heirs, executors, administrators and assigns release, , its officers, employees, servants and agents of and from any and all claims, demands, damages, actions, cause of action of whatever kind or nature.

on account of an accident which occurred on or about the day of at

(Describe briefly injuries and/or d-ge)

I, We, understand that this release is made as compromise to avoid expense and to terminate all controversy and/or claims for injuries or damages of whatever nature, known or unknown, including future developments thereof, in any way growing out of or connected with said accident. I, We, agree that the sum paid is solely by way of compromise of a disputed claim, and it is therefore specifically agreed that this release shall be a complete bar to all claims or suits for injuries or damages of whatsoever nature resulting or to result from said accident.

I, We, further understand that until this release is approved by the Industrial Commission and payment has been received by the claimant, that this release will not become effective.

day of

Witness

Address

Claimant

Address

AGREED TO:

Unit, Agency or Department

By

APPROVED:

Defendant a Attorney

By

The foregoing settlement is hereby approved this day of

NORTH CAROLINA INDUSTRIAL COMMISSION

By

Commissioner

File four completed copies with the Industrial Commission

What the NC Workers' Compensation Form Is and when it is used

The NC Workers' Compensation Form is the standard document used to report a workplace injury or occupational illness in North Carolina and to initiate a claim with an employer's insurer and the North Carolina Industrial Commission. It captures claimant identity, employer and job details, injury date and description, medical treatment information, and any witnesses or incident reports. Accurate completion starts the administrative process for medical payments, wage replacement, and potential disability benefits. The form is typically completed by the injured worker, the employer, or a medical provider and retained by the insurer and employer as proof of notice.

Why accurate completion matters

Completing the NC Workers' Compensation Form accurately ensures timely claim intake, preserves the injured worker's rights, supports correct benefit calculation, and creates an audit trail for medical and payroll records under state and federal recordkeeping obligations.

Who typically completes or signs this form

Multiple parties interact with the NC Workers' Compensation Form depending on the stage: the injured worker, employer representatives, medical providers, and insurance adjusters.

Injured workers submit initial incident details and sign to confirm accuracy and medical treatment requests.
Employers or HR representatives complete employer sections, report wages, and forward the claim to the insurer.
Medical providers complete treatment sections and supply records needed to support benefit eligibility and billing.

Each signer plays a different legal role; preserving accurate contact, employment, and medical details reduces processing delays and disputes.

Primary roles and responsibilities

Employer Representative

Human resources or safety managers must report the injury to the insurer and preserve payroll and incident records. They also supply employment dates, wages, job duties, and internal investigation notes to support claim adjudication and audit trails.

Injured Worker

The injured worker provides a factual description of the event, medical provider details, and signs to indicate they reported the injury. Accurate symptom, date, and witness details help determine compensability and benefit start dates.

Essential fields found on the form

Employee Name: Full legal name

Date of Injury: MM/DD/YYYY

Employer: Company legal name

Job Title: Current position

Medical Provider: Treating facility or clinician

Claim Details: Injury description

Step-by-step: filling and submitting the form

Follow these sequential steps to complete and route the NC Workers' Compensation Form correctly.

01

Record incident: Enter injury date, time, location and brief description.
02

Provide employment data: Add employer name, job title, and usual wages.
03

Attach medical info: Include treating provider and initial diagnosis.
04

Send to insurer: Forward to employer insurer and keep copies.

How to configure a digital completion workflow

Set up the workflow so fields, authentication, and retention meet legal and operational needs.

Field	Configuration
Authentication	Email link or SMS code; use stronger ID for sensitive claims
Conditional Fields	Show employer-only fields after employer role selected
Notifications	Auto-notify HR, insurer, and claimant on submission
Retention	Archive signed PDF with audit trail and access control

Where the completed form should be sent

Identify the document destinations and typical routing after completion.

Employer HR: Retain the signed form in personnel and safety files.
Insurer: Submit to the workers' compensation insurer or third-party administrator.
Medical Records: Share certified medical reports with claims adjuster as authorized.
Industrial Commission: File only when required for contested claims or hearings.

Digital submission and platform considerations

Use secure electronic methods that preserve an audit trail, signer attribution, and document integrity when eSubmitting the form.

Email Delivery: Encrypted email or secure link delivery
E-filing Portals: Insurer portals accept PDF uploads with metadata
Integration: Connect with HRIS, claims, and document management systems

Ensure the chosen platform supports ESIGN/UETA legal requirements, retains an accessible audit trail, and provides secure storage for regulated records.

Timing and promptness best practices

Timely reporting and documentation reduce disputes; follow employer and insurer timelines and file promptly after knowledge of injury.

Report to Employer:

Notify your employer immediately or as soon as practicable after the injury.

Employer to Insurer:

Employers should submit the claim to the insurer within their required reporting window.

Medical Reporting:

Ensure treating providers send initial treatment notes promptly to the claims adjuster.

Objections or Appeals:

File required contest or petition documents per Industrial Commission deadlines.

Record Retention:

Keep all claim documents until resolution plus applicable statutory retention periods.

Key milestones in the claim lifecycle

A clear sequence helps claimants and employers track progress from incident to resolution.

01

Injury Occurs

Immediate medical care and initial reporting to employer.

02

Employer Notice

Employer documents incident and notifies insurer or TPA.

03

Claims Evaluation

Insurer reviews medical records, wage data, and compensability.

04

Payment or Dispute

Insurer authorizes benefits or the claim enters dispute resolution.

Common mistakes to avoid

Using imprecise injury descriptions that omit date, time, or activity leading to the injury.
Submitting mismatched names or incorrect Social Security numbers that block identity verification.
Failing to attach or transmit medical provider notes and initial treatment dates, delaying approval.
Not retaining a signed copy and audit trail, complicating later appeals or wage verifications.

Risks and consequences of incorrect or late filings

Benefit Delay: Payments may be postponed

Denial Risk: Claim may be denied for lack of evidence

Employer Penalties: State fines or administrative penalties possible

Fraud Exposure: False statements can trigger criminal charges

Recordkeeping Violations: Failure to retain records invites compliance action

Appeal Complexity: Incomplete records weaken appeals

Select eSignature pricing and feature snapshot for form workflows

Comparison of common vendor pricing and feature signals for organizations handling NC Workers' Compensation Forms; signNow is listed first per vendor convention.

	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	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
Envelope Cap	No cap	100 envelopes/user/year	No cap	No cap	No cap

Frequently asked questions about the NC Workers' Compensation Form

Answers to common questions about completion, eSigning, submission, and recordkeeping for North Carolina workplace injury claims.

Need help? Contact support

Who must sign the form?
The injured worker should sign to certify facts; employers typically complete employer-specific fields and the insurer or adjuster may acknowledge receipt. Signatures create attribution evidence under the ESIGN Act (15 U.S.C. ch. 96) and state electronic transaction law where applicable.
Can the form be signed electronically?
Yes. Electronic signatures meeting ESIGN and UETA standards are generally valid for workers' compensation documents. Ensure intent, consent, signer attribution, and retention/reproducibility are captured per the four-part ESIGN legal validity test.
What if I need to correct an error?
Do not alter a signed copy. Prepare an amended form or written correction, have the responsible parties sign and date it, and submit both the original and the correction to the insurer to preserve auditability.
Where do I submit the completed form?
Provide the completed form to your employer and the employer should submit it to the insurer or third-party administrator. File with the North Carolina Industrial Commission only if required for hearings or contested claims.
How long must I keep claim documents?
Retain claim files for the active claim plus statutory periods. Follow federal standards for related payroll/tax records (IRS: 3 years, IRC §6501(a)) and health records for six years under HIPAA (45 CFR §164.530(j)).
Are notarization or witnesses required?
Notarization and witness requirements are uncommon for initial workers' compensation claim forms but vary by state and document type; consult the state Industrial Commission or legal counsel if a sworn affidavit or hearing exhibit is involved.

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