North Carolina Industrial Commission Forms on Disc

Form #
Revision Date
Pages
Title
18
Feb-01
1
 Notice of Accident to Employer
18B
Feb-01
2
 Claim by Employee or His Personal Representative or Dependents for Workers' Compensation Benefits
18M
Feb-01
1
 Employee's Claim for Additional Medical Compensation
19
Feb-01
2
 Employer's Report of Injury to Employee
21
Feb-01
2
 Agreement for Compensation for Disability
22
Feb-01
2
 Statement of Days Worked and Earnings of Injured Employee
24
Feb-01
2
 Application to Terminate of Suspend Payment of Compensation
25C
Feb-01
1
 Authorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment
25N
Feb-01
 
 Notice to the Commission of Assignment of Rehabilitation Professional
25P
Feb-01
1
 Itemized Statement of Charges for Drugs
25R
Feb-01
2
 Evaluation for Permanent Impairment
25T
Feb-01
1
 Itemized Statement of Charges for Travel
26
Feb-01
2
 Supplemental Agreement as to Payment of Compensation
26d
Feb-01
1
 Agreement for Compensation
28
Feb-01
1
 Return to Work Report
28b
Feb-01
2
 Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation
28t
Feb-01
1
 Notice of Termination of Compensation by Reason of Trial Return to Work
28u
Feb-01
1
 Employee's Request that Compensation be Reinstated After Unsuccessful Trial Return to Work
29
Feb-01
1
 Supplementary Report for Fatal Accidents
30
Feb-01
2
 Agreement for Compensation for Death
30d
Feb-01
1
 Notice of Death Award
31
Feb-01
1
 Application for Lump Sum Award
33
Feb-01
2
 Request that Claim be Assigned for Hearing
33r
Feb-01
2
 Response to Request that Claim Be Assigned for Hearing
36
Feb-01
2
 Subpoena for Witness
42
Feb-01
2
 Application for Appointment of Guardian Ad Litem
44
Feb-01
2
 Application for Review
51
Feb-01
1
 Annual Consolidated Fiscal Report of "Medical Only" or "Lost Time" Cases
60
Feb-01
1
 Employer's Admission of Employee's Right to Compensation
61
Feb-01
1
 Denial of Workers' Compensation Claim
62
Feb-01
1
 Notice of Reinstatement or Modification of Compensation
90
Feb-01
2
 Report of Earnings
T-1
Feb-01
2
 Claim for Damages Under Tort Claims Act
T-3
Feb-01
1
 Release of Tort Claim
T-44
Feb-01
2
 Application for Review
MSC2
 
1
 Petition for Order Referring Case to Mediated Settlement Conference
MSC4
 
1
 Designation of Mediator
MSC5
 
1
 Report of Mediator
MSC6
 
4
 Mediator's Declaration of Interest and Qualifications
MSC7
 
1
 Report of Evaluator

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