Fill and Sign the What is a Form 28u in North Carolina Workers Compensation

FORM 28U 10/2017 P AGE 1 OF 1 ATTORNEYS /CARRIERS : F ILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP ://WWW .IC.NC .GOV /DOCFILING .HTML E MPLOYEE FILING OPTIONS : E- MAIL TO EXECSEC @IC.NC .GOV F AX TO (919) 715-0282 M AIL TO NCIC-E XECUTIVE SECRETARY 1236 MAIL SERVICE CENTER R ALEIGH , NC 27699-1236 H ELPLINE : (800) 688-8349 W EBSITE : HTTP ://WWW .IC.NC .GOV F ORM 28U North Carolina Industrial Commission IC File # E MPLOYEE 'S R EQUEST THAT C OMPENSATION BE Emp. Code # R EINSTATED A FTER U NSUCCESSFUL T RIAL R ETURN Carrier Code # TO W ORK (G.S. § 97-32.1) Employer FEIN 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 ZipInsurance Carrier ( ) ( ) Home Telephone Work TelephoneCarrier's Address City State Zip XXX-XX- M F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth Carrier's Telephone Number Fax Number SECTION A. E MPLOYEE : COMPLETE AND MAIL TO EMPLOYER AND CARRIER /ADMINISTRATOR , AND TO THE INDUSTRIAL COMMISSION AT THE ADDRESS BELOW : 1. I request that my total disability compensation be resumed immediately. I had a trial return to work with (name of employer) from (date first worked) until (date last worked). The date of m y injury by accident or the date of disabilit y from m y occupational disease was 2. Explain in detail the reasons you are no lon ger workin g: 3. The employee MUST obtain the following from an authorized treating physician: TREATING PHYSICIAN ’S STATEMENT This is to certify that the employee is unable to continue the trial return to work due to the employee’s injury for which compensation has been paid. M y medical specialt y is: SIGNATURE OF AUTHORIZED TREATING PHYSICIAN P RINTED NAME DATE ADDRESS C ITY S TATE Z IP IF RETURN TO WORK WAS WITH THE EMPLOYER FROM WHOM YOU HAVE RECEIVED WORKERS ’ COMPENSATION , SIGN HERE AND DO NOT COMPLETE THE REMAINDER OF THIS FORM . IF RETURN TO WORK WAS WITH A DIFFERENT EMPLOYER , COMPLETE SECTION B BELOW . S IGNATURE OF EMPLOYEE D ATE SECTION B. E MPLOYEE 'S RELEASE OF EMPLOYMENT INFORMATION I hereb y request and authorize m y last emplo yer, (Name and address of last employer) to release to my prior employer and carrier/administrator listed above, or their attorney of record, the following information relating to my trial return to work: first and last date worked, total wages earned, and the reasons this employee is no longer so employed. READ BEFORE SIGNING S IGNATURE OF EMPLOYEE DATE SEND A COPY OF THIS FORM TO THE EMPLOYER AND CARRIER /ADMINISTRATOR FROM WHOM YOU WERE RECEIVING WORKERS ’ COMPENSATION . S END THE ORIGINAL TO THE INDUSTRIAL COMMISSION AT THE ADDRESS BELOW .