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FORM 33 03/2018 P AGE 1 OF 2 ATTORNEYS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW .IC .NC .GOV /DOCFILING .HTML E MPLOYEE FILING OPTIONS : E-MAIL TO DOCKETS @IC.NC .GOV F AX TO (919) 715-0282 M AIL TO NCIC-D OCKET SECTION 1236 M AIL SERVICE CENTER R ALEIGH , NC 27699-1236 H ELPLINE : (800) 688-8349 W EBSITE : HTTP :/ /WWW.IC .NC .GOV F ORM 33 North Carolina Industrial Commission IC File # R EQUEST THAT CLAIM BE ASSIGNED FOR HEARING The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act. ( ) Employee’s Name ( LAST NAME) (FIRST NAME) Employer's Name Telephone Number Address Employer’s Address City State Zip City State Zip Insurance Carrier ( ) ( ) Home Telephone Work TelephoneCarrier's Address City State Zip ฀ M ฀ F / / ( ) ( ) Social Security Number Sex Date of Birth Carrier's Telephone Number Fax Number Date of in jury: Part of bod y: Cit y and count y where the in jury occurred: Estimated length of hearing: This case will be set in the county where the injury occurr ed unless otherwise authorized by the Commission. If the requesting party wants the hearin g to be set in a different count y, name the count y below and the reason for that location. (County) (Reason for setting) I, ____________________________________, ฀ Plaintiff/Attorney ฀ Defendant/Attorney, respectfully notify you that the above named parties have failed to reach an agreement regarding compensation, and I request a hearing. We have been unable to agree because (State reason with specific ity. If appealing an Administrative Order, provide the file date of the Order and the name of the hearin g officer who issued the order. ): Employee believes he or she is entitled to the following workers' compensation benefits (check all that apply): ฀ Pa yment of compensation for da ys missed (give dates ): ฀ Pa yment of medical expenses/treatment: ฀ Pa yment for permanent partial disabilit y: ฀ Payment for permanent and total disability: ฀ Pa yment for scars: ฀ Other: Has claimant participated in mediation? ฀ Yes ฀ No FORM 33 03/2018 P AGE 2 OF 2 ATTORNEYS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW .IC .NC .GOV /DOCFILING .HTML E MPLOYEE FILING OPTIONS : E-MAIL TO DOCKETS @IC.NC .GOV F AX TO (919) 715-0282 M AIL TO NCIC-D OCKET SECTION 1236 M AIL SERVICE CENTER R ALEIGH , NC 27699-1236 H ELPLINE : (800) 688-8349 W EBSITE : HTTP :/ /WWW.IC .NC .GOV F ORM 33 Below is a list of names of all witnesses, including doctors, whose testimony is to be taken by the requesting party. Addresses must be provided for the doctors listed below. NAME ADDRESS I hereby certify that this case is ready for hearing. When a date of hearing is set, I respectfully request the Commission to send me signed subpoenas for my witnesses. When I receive thes e subpoenas, I will serve them pursuant to the instructions on Page 2 of the Industrial Commission Form 36. Signature of Party Requesting Hearing Check one: ฀ Employee, ฀ Employer; ฀ Attorney Printed Name of Party Requesting Hearing Mailing Address: Street and number, city, state and ZIP Code Telephone Number: Date of Notice: E-mail Address: Notice to Employees: The original of this form must be sent to the Industrial Commission at the address below or by e-mail to dockets@ic.nc.gov. A copy of the form must be sent to opposing parties. CERTIFICATE OF SERVICE I hereby certify that on _________________________, I served a copy of this Form 33 Request for Hearing, together with all supporting documents, on the follo wing party(ies) by way of ___________________________________________________________. (U.S. Mail, special delivery mail, e-mail, fax, hand delivery, etc.) [Note: List name and address of each attorney or party served. Attach a separate sheet if necessary.] ___________________________________________________________________________________________________________ Signature Printed Name Date