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. A few forms are in MS Word format and can be filled out and saved. for a list of forms used primarily by Claimants for Workers Compensation cases.
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.
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.
Form 18 With Instructions
Form 18 with Fill-in Fields
Form 18 in MS Word Format
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.
Executive Secretary Forms
Form 18M
Employee’s Application for Additional Medical Compensation (G.S. §97-25.1)
Form 24
Application to Terminate or Suspend Compensation
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
Form 24 Processing Fee
Certification of Up-Front Payment of Form 24 Application Processing Fee
Nursing & Medical Rehabiltiation Forms
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 - MS Word
This is the Form 25C in Microsoft Word Format. Right-Click on the link to download the form.
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) 807-2699
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 EMail your Referral Form in MS Word or PDF format to rehab.referral@ic.nc.gov.
Referral Form - MS Word
Medical Rehabilitation Nurses Section Referral Form in Microsoft Word Format.
Right-Click on the link to download the form.
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) 807-2699
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 EMail your Form 25N in MS Word or PDF format to 25n@ic.nc.gov.
Form 25N - MS Word
This is the Form 25N in Microsoft
Word Format.
Right-Click on the link to download the form.