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Get NC Form 18 2008

North Carolina Industrial Commission IC File NOTICE OF ACCIDENT TO EMPLOYER AND CLAIM OF EMPLOYEE REPRESENTATIVE OR DEPENDENT G.S. 97-22 THROUGH 24 Emp. Code Carrier Code Employer FEIN The I. C. File is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence. The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act Employee s Name Address Employer s Address City State Zip M Social Security Number F / Sex Insurance Carrier Policy Number Carrier s Address Carrier s Telephone Number Carrier s Fax Number Work Telephone Home Telephone Telephone Number Date of Birth EMPLOYEE This form must be filed with the Industrial Commission within two years of the date of injury or occupational disease or your claim may be barred. Notice shall be given to the employer immediately after the accident or as soon as practicable and within 30 days. Employee should retain one signed copy of this notice mail one signed copy to the Industrial Commission at the address below and provide one signed copy to employer. Signature of Check One Employee Attorney Representative or Dependent Date Completed EMPLOYER This notice is being sent to you in compliance with requirements of the North Carolina Workers Compensation Act in order that the medical services prescribed by the Act may be obtained and if disability extends beyond 7 days duration or if death ensues compensation may be paid according to law. FOR IC USE ONLY FORM 18 8/08 PAGE 1 OF 1 MAIL TO NCIC - CLAIMS ADMINISTRATION RESEARCHER CC DATA ENTRY 4335 MAIL SERVICE CENTER RALEIGH NORTH CAROLINA 27699-4335 MAIN TELEPHONE 919 807-2500 HELPLINE 800 688-8349 WEBSITE HTTP //WWW.IC. North Carolina Industrial Commission IC File NOTICE OF ACCIDENT TO EMPLOYER AND CLAIM OF EMPLOYEE REPRESENTATIVE OR DEPENDENT G*S* 97-22 THROUGH 24 Emp* Code Carrier Code Employer FEIN The I. C. File is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence. The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act Employee s Name Address Employer s Address City State Zip M Social Security Number F / Sex Insurance Carrier Policy Number Carrier s Address Carrier s Telephone Number Carrier s Fax Number Work Telephone Home Telephone Telephone Number Date of Birth EMPLOYEE This form must be filed with the Industrial Commission within two years of the date of injury or occupational disease or your claim may be barred* Notice shall be given to the employer immediately after the accident or as soon as practicable and within 30 days. This form should also be used for occupational disease claims however for asbestosis silicosis and byssinosis Form 18B is to be used* Notice is hereby given as required by law that the above-named employee sustained an injury or contracted an occupational disease on described as follows Time of Injury at Date required. Describe the injury or occupational disease City and County including the specific body part involved e*g* right hand left hand Describe how the injury or occupational disease occurred Occupation when injured Nature of employer s business Number of days out of work due to injury Medical treatment received Yes No Weekly wage Number of hours worked per day Days worked per week NOTE If employee is unable to sign this form another may sign for him* This form should be typed or printed by hand in black ink if possible. .

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