Get Itemized Statement Of Charges For Travel - North Carolina

The Itemized Statement Of Charges For Travel - North Carolina is a crucial document for individuals seeking reimbursement for travel expenses related to workers' compensation cases. This guide provides clear and supportive instructions on how to accurately complete the form online.

Follow the steps to effectively fill out the statement of charges.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the employee's name, ensuring correct spelling and format. This is essential for accurate identification.
3. Next, fill in the employer's name and the corresponding addresses—both home and work—making sure all information is accurate and complete.
4. Provide the last four digits of the employee's social security number and their date of birth, as this helps in confirming identity.
5. Indicate the sex of the employee by selecting the appropriate checkbox.
6. Document the date of the accident or the onset of the disability from occupational disease clearly.
7. Address whether the salary was continued by checking the respective box.
8. For sections 3 through 7, input the number of weeks and total dollar amounts for temporary total, temporary partial, permanent partial, disfigurement, and loss of organ or body part benefits accordingly.
9. Calculate the total of lines 3 through 7 and enter it in the designated field.
10. Enter the Compromise Settlement Agreement amount and total medical paid, ensuring each figure reflects the correct amounts.
11. Once all information is filled out, review the form for any errors before proceeding to save your changes, download, print, or share the completed document.

Complete your documents online today for a seamless process.