We use cookies to improve security, personalize the user experience, enhance our marketing activities (including cooperating with our marketing partners) and for other business use.
Click "here" to read our Cookie Policy. By clicking "Accept" you agree to the use of cookies. Read less
Read more
Accept
Loading
Form preview
  • US Legal Forms
  • Form Library
  • Labor Forms
  • North Carolina Labor Forms
  • Nc Ic Form 25t 2019

Get Nc Ic Form 25t 2019-2025

FORM 25T 01/2019 PAGE 1 OF 1 NOTICE TO INJURED EMPLOYEE THIS FORM SHOULD BE RETURNED TO THE CARRIER AT THE ADDRESS ABOVE FOR PAYMENT. 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 Compensation Act Employer FEIN Employee s Name Address Employer s Address City State - Home Telephone Zip Telephone Number Insurance Carrier Work Telephone Carrier s Address Carrier s Telephone Number Fax Number Employees are entitled to reimbursement of 0. 58 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2019. Special consideration will be given to employees who are totally disabled* No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. These items must be purchased on visits to medical providers G*S* 97-25. DATE / NAME OF MEDICAL PROVIDER OTHER EXPENSES If....

How it works

  1. Open form

    Open form follow the instructions

  2. Easily sign form

    Easily sign the form with your finger

  3. Share form

    Send filled & signed form or save

How to fill out the NC IC Form 25T online

Filling out the NC IC Form 25T online is a straightforward process that ensures you can submit your itemized statement of charges for travel related to workers' compensation. This guide will walk you through each step to complete the form efficiently.

Follow the steps to fill out the NC IC Form 25T online:

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Enter your employee code, carrier code, and carrier file number in the designated fields.
  3. Provide your employer's Federal Employer Identification Number (FEIN). Fill in your name and your employer's name as requested.
  4. Complete the address fields for both your employer and the insurance carrier, including city, state, and zip code.
  5. List your home telephone number and the work telephone number of the insurance carrier.
  6. Indicate the total miles roundtrip that you have traveled for medical treatment and document the date of each trip.
  7. Fill in the name of the medical provider you visited and provide any additional expenses related to the travel.
  8. Calculate and enter the totals for mileage, motel expenses, meal expenses, and any other expenses, ensuring to include receipts if required.
  9. Certify the expenses incurred by providing your signature and submit the completed form.
  10. Save changes, download, print, or share the form as needed to ensure it is sent to the appropriate parties.

Complete your documents online today for a smoother submission process.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Get form

Related content

Itemized Statement of Charges for Travel
FORM 25T. North Carolina Industrial Commission. IC File #. ITEMIZED STATEMENT OF CHARGES...
Learn more
11 N.C. Admin. Code 23J .0101 - GENERAL PROVISIONS
The current reimbursement rates referenced in this Paragraph are contained in the Form...
Learn more
and polyfluoroalkyl substances on fire suppression...
by JR Lang · 2022 · Cited by 27 — Fire suppression systems are known to be impacted...
Learn more

Related links form

Sanbs Donor Questionnaire 2020 Modelo 005 Arona 2020 Nyc Rent Stabilized Lease Form Pdf 2020 SC Recertification Computation Sheet - Richland2

Questions & Answers

Get answers to your most pressing questions about US Legal Forms API.

Contact support

In North Carolina, businesses with three or more employees must provide workers' compensation coverage. Coverage ensures that employees receive benefits when injured on the job. To initiate a claim, use the NC IC Form 25T to document your injury, associated costs, and necessary details. Being informed about these requirements supports both employers and employees in protecting their rights.

Tennessee's workers' compensation system provides medical care and wage replacement for injured workers. Employees must report their injuries to their employer, who will then file a claim with their insurance provider. While the NC IC Form 25T is specific to North Carolina, understanding the procedures in Tennessee can help you navigate similar processes effectively.

In South Dakota, you must report a work injury to your employer within three days of the incident. This prompt reporting is important for ensuring your rights to benefits under workers' compensation. While the NC IC Form 25T pertains to North Carolina, be aware of specific local laws regarding deadlines and requirements in South Dakota to ensure you file your claim correctly.

To fill out a workers' comp form, you should carefully enter your personal information, details about your injury, and any medical treatments. Start with the NC IC Form 25T, which is specifically designed for North Carolina claims. Ensure you gather all required documentation, such as medical records and employer information, to support your claim effectively and accurately.

When speaking with a workers' comp doctor, avoid making statements that might downplay your injury, such as claiming your pain is minor. Also, do not suggest you might have been at fault for the injury. These comments can complicate your case, so it is vital to communicate honestly and clearly about your condition using the NC IC Form 25T as needed.

Filing a workers' comp claim can be worthwhile if you have a legitimate injury that affects your ability to work. Benefits can include coverage of medical expenses and lost wages. By using the NC IC Form 25T, you enhance your chances of receiving appropriate compensation and support during your recovery journey.

In North Carolina, you qualify for workers' comp if you have a work-related injury or illness that arose during your employment. This includes injuries sustained on the job site or illnesses caused by repetitive motions. To establish a valid case, ensure you have documentation, such as the NC IC Form 25T, detailing your condition and how it relates to your work.

To file a workers' comp claim in North Carolina, you first need to report your injury to your employer. Then, you should complete the relevant forms, such as the NC IC Form 25T, and submit them to the North Carolina Industrial Commission. It’s essential to follow the guidelines carefully to avoid delays in your claim process.

Receiving a workers' comp settlement check in North Carolina can take several weeks to a few months, depending on various factors. These factors include the negotiation process and paperwork completion. Once everything is finalized, the check is typically processed and mailed promptly. If you find the process confusing, platforms like uslegalforms can guide you through and ensure that everything is in order.

In North Carolina, certain groups may be exempt from workers' compensation coverage. This includes independent contractors, small employers with fewer than three employees, and specific agricultural workers. Understanding your status can help you navigate your rights and responsibilities. If you are unsure, consult legal resources or platforms like uslegalforms for assistance.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
Get form
If you believe that this page should be taken down, please follow our DMCA take down processhere.

Industry-leading security and compliance

US Legal Forms protects your data by complying with industry-specific security standards.
  • In businnes since 1997
    25+ years providing professional legal documents.
  • Accredited business
    Guarantees that a business meets BBB accreditation standards in the US and Canada.
  • Secured by Braintree
    Validated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.
Get NC IC Form 25T
Get form
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Help Portal
Legal Resources
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Help Portal
Legal Resources
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232