NORTH CAROLINA INDUSTRIAL COMMISSION

Help Line: (800) 688-8349, (919) 807-2501, or infospec@ic.nc.gov
Fraud and Insurance Compliance Hotline: (888) 891-4895 or fraudcomplaints@ic.nc.gov

NCIC Forms

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 in electronically and printed for submission.

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.

For Claimants

Click Here for a list of forms used primarily by Claimants for Workers Compensation cases.

For Employers

Click Here for a list of forms used primarily by Employers for Workers Compensation cases.

Nursing and Medical Rehabilitation

Clicking Here will take you to a list of forms used by the Nursing and Medical Rehabilitation Section.

Claimant Forms

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 18 for Electronic Submission

Standard Form 18 With Instructions

Form 18B

Claim by Employee, Representative, or Dependent for Lung Disease, Including Asbestosis, Silicosis, and Byssinosis (G.S. §97-53)

Form 18M

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)

Form 25P

Itemized Statement of charges for Drugs

Form 25T

Itemized Statement of Travel Charges

Form 31

Application for Lump Sum Award

Form 33

Request that Claim be assigned for Hearing

Form 42

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.

Employer Forms

Form 19

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 forms@ic.nc.gov. 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.

Standard Form 19 with Instructions

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.

Form 17

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.)

Form 18

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.

Form 18 for Electronic Submission

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.

Standard Form 18 With Instructions

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.

Executive Secretary Forms

Form 18M

Employee’s Application for Additional Medical Compensation (G.S. §97-25.1)

Form 23

Application to Reinstate Payment of Disability Compensation (G.S. §97-18(k))

Form 24

Application to Terminate or Suspend Compensation

Form 24 Processing Fee

Certification of Up-Front Payment of Form 24 Application Processing Fee

Form 28U

Request for Reinstatement of Compensation after Unsuccessful Trial Return to Work

CSA Processing Fee

Certification of Up-Front Payment of Compromise Settlement Agreement Processing Fee

Nursing & Medical Rehabilitation Forms

Form 25C

Form 25C - 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.

Form 25C - PDF Format

Click here to download the PDF version of Form 25C.

Referral Form

Medical Rehabilitation Nurses Section Referral Form. Please fill out this form completely, making sure to include the I.C. Number for the claim. Please fax the completed and signed Form to
(919) 508-8350
ATTN: Medical Rehabilitation Nurses
.

The completed form can be mailed to us at:
NC Industrial Commission
4341 Mail Service Center
Raleigh, NC 27699-4341
ATTN: Medical Rehabilitation Nurses

You can also e-mail your Referral Form in PDF format to rehab.referral@ic.nc.gov.

Referral Form - PDF Format

Click to download the PDF version of the Medical Rehabilitation Nurses Section Referral Form.

Form 25N

Form 25N - 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 fax the completed and signed Form 25N to
(919) 508-8325
ATTN: Medical Rehabilitation Nurses
.

The completed form can be mailed to us at:
NC Industrial Commission
4341 Mail Service Center
Raleigh, NC 27699-4341
ATTN: Medical Rehabilitation Nurses

You can also e-mail your Form 25N in PDF format to 25n@ic.nc.gov.

Form 25N - PDF Format

Click here to download the PDF version of the Form 25N.

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