North Carolina Industrial Commission IC File # ITEMIZED STATEMENT OF CHARGES FOR TRAVEL Emp. Code # Carrier Code # Carrier File # The Use of This Form Is Required Under the Provisions of the Workers.
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How to fill out the Form 25t online
Filling out the Form 25t is an important step in the process of seeking reimbursement for travel expenses related to medical treatment under the Workers' Compensation Act. This guide provides a clear, step-by-step approach to help you complete the form accurately and efficiently.
Follow the steps to successfully complete the Form 25t online.
- Click the ‘Get Form’ button to obtain the form and access it in the online editor.
- In the first section, enter your employee code, carrier code, and carrier file number as required. These numbers are essential for identifying your claim.
- Fill in your employer's Federal Employer Identification Number (FEIN) along with the employer's name and address details. Make sure to provide accurate information to avoid processing delays.
- Next, complete the section for the employee's name, home telephone number, and residential address, including city, state, and zip code.
- In the insurance carrier section, input the carrier's address, city, state, zip, and telephone number. Ensure this information is detailed and exact.
- Document your travel details, beginning with the date of travel and the name of the medical provider. Additionally, complete the total miles traveled roundtrip.
- Fill in any other expenses incurred, such as total motel expenses, meal expenses, and any parking or cab charges. Ensure you keep receipts for these expenses.
- Calculate the total of all expenses and enter this at the bottom of the expense section. Ensure that all calculations are accurate for proper reimbursement.
- Sign the form to certify that you have incurred all listed expenses due to your workers' compensation injury.
- Once you have completed the form, save your changes, and use the download feature to save a copy. You may also print or share the filled form if needed.
Start completing your forms online to ensure timely processing of your expenses.
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Get answers to your most pressing questions about US Legal Forms API.
What is Form 22 NC Industrial Commission?
Form 22 is used in workers' compensation claims to calculate the injured employee's average weekly wage and resulting weekly disability compensation rate based on earnings for the 52 weeks prior to the date of injury.
What does the NC Industrial Commission do?
The Industrial Commission administers the Workers' Compensation Act, the Tort Claims Act, the Childhood Vaccine-Related Injury Act, the Public Safety Employees' Death Benefits Act, the Act to Compensate Individuals Erroneously Convicted of Felonies, and the Eugenics Compensation Program.
What is a Form 61 in NC?
A "Form 61" is the official North Carolina Industrial Commission form used by insurance companies to DENY workers' compensation claims. If you get a "Form 61" that means that your case is being declined or denied, and no further cash or medical benefits will be provided to you after the date on the Form 61.
What is a Form 22 for workers comp in North Carolina?
North Carolina Industrial Commission Form 22 is the Statement of Days Worked and Earnings of Injured Employee. This form contains a table wherein the hours worked and wages earned over the 52 weeks prior to the employee's injury are recorded.
What is a 22 form?
FORM 22 – Application for Company Information Updates and Registration Cancellations 1. Company Name: 2. Change to Company Inf. Page 1. STATE OF CALIFORNIA.
What is the mileage of 25t?
A: ARAI mileage of TNT 25 is 25 kmpl. Fuel economy of Benelli TNT 25, as reported by its owners, is 26 kmpl.
How long do you have to report a work related injury in North Carolina?
Under North Carolina law, every injured worker — or their official representative — should report an accident to an employer immediately or as soon as it is practicable. The notice must be given within 30 days of the date of the accident.
What is a first report of injury NC?
The First Report of Injury is one of the forms you must fill out for any work related Injury, Illness, or Near Miss. This form along with the Worker's Compensation Form 19 will be used for Worker's Compensation consideration. Return the completed and signed form to EHS Box 8007.
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