Get Form 28c

Filling out the Form 28c online is a critical step in reporting compensation and medical payments as required by the North Carolina Industrial Commission. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete Form 28c online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the employer's information, including the employer code, carrier code, and carrier file number. Ensure all fields are filled out accurately.
3. Fill in the employer's FEIN (Federal Employer Identification Number) and the employee's name. This section helps to clearly identify all parties involved.
4. Provide the addresses for both the employer and the insurance carrier, including city, state, and zip code. This information is crucial for accurate communication.
5. Input the home and work telephone numbers, as well as the employee's social security number and date of birth. Ensure all personal information is entered correctly.
6. Next, document the date of the accident or the onset of disability from occupational disease. This is critical for claims processing.
7. Record the salary details and the number of weeks for temporary total compensation, indicating if it was continued or not. Include all necessary amounts during the specified periods.
8. Continue filling out the form with the information regarding temporary partial and permanent partial compensation, including the relevant time spans and total amounts.
9. Document any disfigurement amounts and loss of organ or body part benefits paid. Make sure all monetary values are accurate.
10. Calculate the total from lines 3 through 7 and enter it in the designated space. This will provide a sum of all compensation paid.
11. Finally, enter the compromise settlement agreement amount and the total medical costs incurred. Review all entries to confirm their accuracy.
12. Complete the form by providing the name of the employer or carrier/administrator, signing it, and dating it. This will make the document official.
13. After finishing, ensure to save changes, and then download, print, or share the form as necessary. Follow any specific instructions for submitting the form to the Industrial Commission.

Ready to submit your Form 28c? Fill it out online today for a smooth filing process.