Workers Compensation Forms
All current forms used by the NC Industrial Commission can be found here. Most are in PDF format and will require Adobe Reader to view or print. Some forms may be filled and printed for submission electronically, per 04 NCAC 10A .0108, effective February 1, 2016.
NOTE: Since the Industrial Commission uses an electronic document management system to scan and electronically store all forms and other correspondence received by us, we require that all forms be submitted on white paper. NO forms on colored paper will be accepted.
Click Here for a list of forms used primarily by Claimants for Workers Compensation cases.
Click Here for a list of forms used primarily by Employers for Workers Compensation cases.
Clicking Here will take you to a list of forms used by the Nursing and Medical Rehabilitation Section.
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 email@example.com.)
Claim by Employee, Representative, or Dependent for Lung Disease, Including Asbestosis, Silicosis, and Byssinosis (G.S. §97-53)
Employee’s Application for Additional Medical Compensation (G.S. §97-25.1) (Applicable to Injuries by Accident or Occupational Illness on or After July 5, 1994)
Itemized Statement of Charges for Drugs
Itemized Statement of Travel Charges
Application for Lump Sum Award
Request That Claim Be Assigned for Hearing
Application for Appointment of Guardian Ad Litem
This form is used when the claimant is an infant or incompetent person has no general or testamentary Guardian. In civil actions in North Carolina when any of the parties is an infant or incompetent person, he or she must appear by general or testamentary guardian, if he or she has any within this State, or by guardian ad litem.
This is the first report of injury (FROI) that an employer submits when an employee has a claim. Effective June 1, 2014, all first reports of injury (FROI) for injuries occurring after April 1, 1997 must be filed electronically via EDI unless they qualify for one of two exceptions. The only exceptions to electronic filing of FROI's are claims (1) in which a Form 18 was previously filed and a six-character alphanumeric number has already been assigned, or (2) for an occupational disease in which a Form 18B has already been filed.
If the claim meets one of the two exceptions listed above, the Form 19 may be downloaded, printed, filled out, and mailed into the N.C. Industrial Commission, faxed to the N.C. Industrial Commission at 919-715-0282, or e-mailed to firstname.lastname@example.org. Please note that if the claim does not meet one of the exceptions outlined above, the Form 19 will be returned without processing, and a FROI must be submitted via EDI.
This Form 19 may be downloaded, printed, filled out and mailed into the NC Industrial Commission. Please read the attached instructions for required information and the mailing address.
N.C. Workers’ Compensation Notice to Injured Workers and Employers. This form MUST be prominently posted if you have Worker's Compensation Insurance or qualify as Self-Insured. (N.C. Gen. Stat. §97-93). (Click here for the Spanish Form 17.)
Employers are required to provide this form whenever a report of injury or occupational disease has been received from an employee. This form MUST be filled out completely by the employee and submitted to the Industrial Commission in addition to the Form 19.
This version of the Form 18 allows for filling out and submitting it on-line. You must have Adobe Reader version 7.0 or later and a valid e-mail address to submit this form on-line. Click Here to get the free Adobe Reader.
This Form 18 may be downloaded, printed, filled out and mailed into the NC Industrial Commission. Please read the attached instructions for required information and the mailing address.
Employee’s Application for Additional Medical Compensation (G.S. §97-25.1)
Application to Reinstate Payment of Disability Compensation (G.S. §97-18(k))
Application to Terminate or Suspend Payment of Compensation (click here for a fillable Form 24)
Medical Rehabilitation Nurses Section Referral Form. Please use this form to request assistance from the Medical Rehabilitation Nurses Section. Fill out the form completely, making sure to include the I.C. Number for the claim, if possible; and e-mail the completed form to email@example.com.
The completed form can be mailed to us at:
NC Industrial Commission
4341 Mail Service Center
Raleigh, NC 27699-4341
ATTN: Medical Rehabilitation Nurses
Authorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment. Please fill out this form completely, sign it, and mail it to the rehabilitation professional named on the form.
Notice to the Commission of Assignment of Rehabilitation Professional. Please fill out this form completely, making sure to include the I.C. Number for the claim. Please e-mail the completed and signed Form 25N to firstname.lastname@example.org.