North Carolina Report of Injury by Employee to Employer to be Filed with Worker's Compensation Agency of State

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Description

Workers' compensation laws are designed to ensure payment by employers for
some part of the cost of injuries, or in some cases of occupational diseases, received by employees in the course of their work. Worker's compensation legislation requires the employer to furnish a reasonably safe place to work, suitable equipment, rules and instructions. State workers' compensation statutes vary by state. The Federal Employment Compensation Act covers non-military federal employees or those workers employed in some significant aspect of interstate commerce.


The compensation acts require that notice of the fact of injury be given to the employer, or to the compensation board or commission, or to the insurance carrier, or to all of them. This form is a generic example that may be referred to when preparing such a form for your particular state. It is for illustrative purposes only. Local laws should be consulted to determine any specific requirements for such a form in a particular jurisdiction.

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FAQ

Form 25T - This is a form to List an Itemized Statement of Charges for Travel. Employees are entitled to reimbursement for mileage if the employee travels 20 miles or more round trip for medical treatment. Form 24 - This is an Application to Terminate or Suspend Payment of Compensation.

Form 18. This is where you begin when you have a claim. This form MUST be filled out completely and submitted to the Industrial Commission when you have been injured on the job. (Note: Please e-mail completed forms to forms@ic.nc.gov.)

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. If it is not, workers' compensation benefits may not be payable.

Benefit Amount: Two-Thirds of Your Average Weekly Earnings In most cases, long-term employees can receive approximately two-thirds of their average weekly earnings as workers' compensation. This benefit provides financial stability while recovering from a workplace injury.

A worker may submit a written report to his or her supervisor, or the worker may choose to file a Form 18 with the North Carolina Industrial Commission, then submit a copy of the form to the employer.

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.

A Form 18 establishes a legal claim of injury on your behalf if filed within two years of the date of injury or occupational disease, and gives the required written notice to the employer if a copy is submitted to the employer within 30 days of the injury.

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North Carolina Report of Injury by Employee to Employer to be Filed with Worker's Compensation Agency of State