FORM 25T 12/2013 PAGE 1 OF 1 FOR ASSISTANCE CALL N.C. INDUSTRIAL COMMISSION MAIN TELEPHONE 919 807-2500 WORKERS COMPENSATION INFORMATION SPECIALISTS 800 688-8349. 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. 56 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2014. 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 / TOTAL MILES R....
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How to fill out the NC IC Form 25T online
Filing the NC IC Form 25T online is essential for employees requesting reimbursement for travel expenses related to medical treatment under the Workers' Compensation Act. This guide provides detailed instructions on how to navigate the form easily and accurately.
Follow the steps to successfully complete the form.
- Press the ‘Get Form’ button to access the form and open it in the editor.
- Begin by entering the employee's and employer's information in the corresponding fields. This includes the employee’s name, employer's name, FEIN, and contact information.
- Input the insurance carrier details, including the carrier code and file number. Ensure to verify the contact number and address for accuracy.
- In the expenses section, fill in the date of travel, total miles traveled round trip, the name of the medical provider, and any other expenses incurred during the trip.
- Calculate the total reimbursement by multiplying the total miles by the applicable mileage rate, which is currently $0.56 per mile. Additionally, include any approved overnight stay or meal expenses, as well as other related expenses.
- certify the accuracy of the expenses by signing in the designated area. Once all sections are complete, review the information for correctness.
- After completing the form, you can save your changes, download the document for your records, print it, or share it as needed.
Complete the NC IC Form 25T online to ensure timely processing of your travel expense reimbursement.
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Get answers to your most pressing questions about US Legal Forms API.
What is the mileage reimbursement form for workers comp in NC?
In North Carolina, the mileage reimbursement form allows employees to claim reimbursement for travel related to their work injury treatment. This form covers cumulative travel expenses incurred while attending medical appointments. Ensure you fill it out clearly, and consider using the NC IC Form 25T to navigate your rights effectively.
How long does an employer have to file a workers comp claim in North Carolina?
In North Carolina, an employer must file a report for a workers' comp claim within 30 days. This timeframe is critical for both parties to ensure that the claim is processed without unnecessary delay. Timely reporting also helps secure your benefits and protects your rights.
Can you file a workers comp claim after termination?
Yes, you can file a workers' comp claim after termination as long as it is filed within the legal timeframe. Your entitlement to benefits does not end upon termination, especially if the injury occurred while you were employed. Consult the NC IC Form 25T for detailed instructions on submitting your claim.
What is the requirement for workers' compensation in NC?
In North Carolina, almost all employers are required to carry workers' compensation insurance. This coverage is essential for protecting employees from financial loss due to work-related injuries. If you are unsure about your rights and obligations, the NC IC Form 25T can guide you through the necessary steps.
Is there a time limit on compensation?
Yes, in North Carolina, there is a time limit on compensation for workers' comp claims. After a claim is approved, you may receive benefits for a certain period, depending on the severity of your injury. It's crucial to understand these time limits, as they can affect your financial recovery.
How late can you file a workers' comp claim?
Workers in North Carolina have a strict deadline to file a workers' comp claim. You must file within two years from the date of injury or diagnosis of an occupational disease. If unsure about the timeline, utilizing resources like the NC IC Form 25T can help clarify your eligibility.
How long does an employer have to file a workers' comp claim in NC?
In North Carolina, employers have 30 days to report a workers' comp claim to their insurance company following knowledge of an injury. This prompt reporting is essential for ensuring that the claim process begins smoothly. By filing within this period, both the employer and employee can avoid potential delays in compensation.
How to fill out a Workmans Comp form?
To fill out a Workmans Comp form, start by gathering necessary information such as your personal details, the details of your employer, and the specifics of your injury. Make sure to accurately describe how the injury occurred and what treatment you received. If you need guidance, consider using the NC IC Form 25T to help provide all required information correctly.
How to fill out workers' comp paperwork?
When filling out workers' comp paperwork, including the NC IC Form 25T, start by gathering all relevant information about the injury and your employment. Be clear and detailed in your description, ensuring you provide accurate dates and any related medical documentation. If you find the process overwhelming, consider using services like USLegalForms, which provide helpful resources and templates to simplify the experience.
How to file for workers' comp in NC?
To file for workers' comp in North Carolina, begin by reporting your injury to your employer as soon as possible. You will need to complete the NC IC Form 25T, which outlines the details of your injury and the situation surrounding it. After your employer submits the claim to their insurance, ensure you follow up on its status to avoid any complications.
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