Note: The following constitutes the proposed
changes in this Rule. Added language appears in bold italic script, and
proposed deletions are indicated by strikeout. The changes will not go
into effect until further notice by the Industrial Commission.
Rule 103
Official Forms
(1) The Industrial Commission will supply, on request, forms identified by number and title as follows:
Form 17 Workers’ Compensation Notice
Form 18 Notice of Accident to Employer
(N.C. Gen. Stat. § 97-22)and Claim of Employee or His Personal Representative or Dependents (N.C. Gen. Stat. § 97-22 through 24)Form 18B Claim by Employee or His Personal Representative or Dependents for Workers’ Compensation Benefits for Lung Damage, Including Asbestosis, Silicosis, and Byssinosis (N.C. Gen. Stat. § 97-53)
Form 18M Employee’s Claim for Additional Medical Compensation
Form 19 Employer’s Report of Employee’s Injury to
Employeethe Industrial CommissionForm 21 rev. Agreement for Compensation for Disability Pursuant to N.C. Gen. Stat. § 97-82
Form 22 Statement of Days Worked and Earnings of Injured Employee (Wage Chart)
Form 24 rev. Application to Terminate or Suspend Payment of Compensation Pursuant to N.C. Gen. Stat. § 97-18.1
Form 25D Dentists’ Itemized Statement of Charges for Treatment and Certification of Treatment of Disability
Form 25M Physician’s Itemized Statement of Charges for Treatment and Certification of Treatment
Form 25R rev. Evaluation for Permanent Impairment
Form 25T Itemized Statement of Charges for Travel
Form 25P Itemized Statement of Charges for Drugs
Form UB-92 Hospital Bill
Form 26 rev. Supplemental Agreement as to Payment of Compensation Pursuant to N.C. Gen. Stat. § 97-82
Form 26D Agreement for Compensation Under N.C. Gen. Stat. § 97-37
Form 28 rev. Return to Work Report
Form 28B rev. Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation
Form 28T Notice of Termination of Compensation by Reason of Trial Return to Work Pursuant to N.C. Gen. Stat. § 97-18.1(b) and N.C. Gen. Stat. § 97-32.1
Form 28U Employee’s Request that Compensation be Reinstated After Unsuccessful Trial Return to Work Pursuant to N.C. Gen. Stat. § 97-32.1
Form 29 Supplementary Report for Fatal Accidents
Form 30 Agreement for Compensation for Death
Form 30D Notice of Death Award (Approval of Agreement)
Form 31 Application for Lump Sum Award
Form 33 Request that Claim be Assigned for Hearing
Form 33R Response to Request that Claim be Assigned for Hearing
Form 36 rev. Subpoena for Witness and Subpoena to Produce Items or Documents
Form 42 Application for Appointment of Guardian Ad Litem
Form 44 Application for Review
Form 50 Itemized Statement of Charge for Nursing
Form 51 Consolidated Fiscal Annual Report of "Medical Only" and "Lost Time" Cases
Form 60 Employer’s Admission of Employee’s Right to Compensation Pursuant to N.C. Gen. Stat. § 97-18(b)
Form 61 Denial of Workers’ Compensation Claim Pursuant to N.C. Gen. Stat. § 97-18(c) and (d)
Form 62 Notice of Reinstatement of Compensation Pursuant to N.C. Gen. Stat. § 97-32.1 and N.C. Gen. Stat. § 97-18(b)
Form 63 Notice to Employee of Payment of Compensation Without Prejudice to Later Deny the Claim Pursuant to N.C. Gen. Stat. § 97-18(d)
Form IZ-510 Medical Bill Analysis Used for Approval and Reduction of Medical Bills
The mailing address for each Industrial Commission Form appears at the bottom right corner of the Form.
(2) The use of any printed forms other than those approved and adopted
by the Industrial Commission is prohibited. Insurance carriers, self-insureds, attorneys
and other parties may photocopy reproduce approved forms
for their own use, provided:
(a) The color of the paper upon which the form is printed may be substantially identical to that used on the approved Industrial
Commission’s form, at the option of the Employer or Carrier/Administrator and the Employee.(b)(a) No statement, question, or information blank contained on the approved Industrial Commission’s form is omitted from the substituted form.
(c)(b) Such substituted form is substantially identical in size and format with the approved Industrial Commission’s form.
(3) The following forms may be utilized in preparing routine orders for the signature of a Commissioner or Deputy Commissioner, and are appended at the end of these Rules:
Form I Order for Third Party Recovery Distribution per N.C. Gen. Stat. § 97-10.2
Form IIa Order Approving Compromise Settlement Agreement (admitted liability, medical paid) and Third Party Distribution
Form IIb Order Approving Compromise Settlement Agreement (denied liability, unpaid medical) and Third Party Distribution
Form IIIa Order for Approving Compromise Settlement Agreements (admitted liability, medical paid)
Form IIIb Order for Approving Compromise Settlement Agreements (denied liability, unpaid medical)
(4) Copies of rules, forms and Industrial Commission Minutes can be
obtained by contacting the Administrator’s Office of the Industrial Commission, 430
N. Salisbury Street, Raleigh, North Carolina 27611 4319 Mail Service
Center, Raleigh, NC 27699-4319.
(5) The Amendments to this Rule are effective March 15,
1995, except as to Form 28T, Form 28U, and Form 62 which are effective
February 15, 1995.
(Amended effective January 1, 1992; Amended
Go Back to January 10, 2000 Proposed Notice of Rule-Making Page
Return to N.C. Industrial Commission Home Page
Return to NCIC Alternate Home Page
N.C. Industrial Commission · 4319 Mail Service Center · Raleigh, NC 27699-4319