North Carolina Sample Letter for Legal Representation - Worker's Compensation
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How to fill out Sample Letter For Legal Representation - Worker's Compensation?
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FAQ
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.
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.
Form 61 ? Employer Form This form means that you will receive no compensation for your missed time from work or medical treatment unless you can convince the NCIC to overturn this decision at hearing (or at the mediation that comes prior to the hearing).
Form 19. This is the first report of injury (FROI) that an employer submits when an employee has a claim.
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.)
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.
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.
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.