NORTH CAROLINA INDUSTRIAL COMMISSION

Workers' Compensation HELP: (800) 688-8349 or (919) 807-2501

Legal Notice

NC Workers’ Compensation Form 19 for Electronic Submission

Employer's Report of Employee's Injury or Occupational Disease to The Industrial Commission
Digital Signature Required

Submission of this form electronically requires the use of a digital signature. The North Carolina Electronic Commerce Act, N.C.G.S. § 66-58.1, authorizes the North Carolina Industrial Commission to accept digital signatures in place of manual signatures. Your digital signature on this form has the same legal effect as your manual signature.

Digital Signature and Electronic Submission of Form Complies with Directions and Instructions on Form

Applying your digital signature to the form will submit the digitally-signed form directly to the Commission via email; this action satisfies the requirement of the direction on the face of the form requiring the mailing of a copy of the form to the Commission. You do not need to mail a copy of this form to the Commission after you have submitted the form electronically.

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