N.C. Industrial Commission Forms

NCIC Forms on White Paper Only: The Industrial Commission requires that all forms be submitted on white paper and no colored forms will be accepted from this point forward due to the use of an electronic document management system. Paper forms are converted to images and the color is no longer useful but degrades the quality of the electronic image.

Discontinued Forms: N.C. Industrial Commission Forms 25A, 25D, 25M, and 50 have been discontinued. Form 25D has been replaced by the American Dental Association-accepted claim form, and Form 25M has been replaced by Form CMS-1500 (formerly Form HCFA-1500) from the Centers for Medicare & Medicaid Services of the U.S. Department of Health & Human Services. (For more information on Form CMS-1500 from the National Uniform Claim Committee (NUCC), click here. To get a sample of the CMS-1500, complete with instructions, please click here. For just the form alone, please click here.) Forms 25D and 25M were only accepted through 1 June 2001; now, physicians and dentists must use the other forms. Please click here for information on the UB-04 Uniform Billing form (formerly Form UB-92 or HCFA-1450).

EDI: The Electronic Data Interchange (EDI) affords insurers and the N.C. Industrial Commission a method of exchanging certain information electronically and thereby avoiding multiple entry of data into the computer system. EDI is fast, accurate, reliable, and cost effective. Many insurers nationwide use EDI routinely, and the Industrial Commission is working hard to make this service available for filing workers’ compensation data. Insurers who agree to send documents electronically sign an agreement with Commission. The agreement includes testing the reporting system to determine if the transmission mechanism is acceptable. Insurers must resend any data that is incomplete or invalid. Click here for a Microsoft® Word document showing the file layout of the International Association of Industrial Accident Boards and Commissions (IAIABC) and the data elements that are required by the N.C. Industrial Commission.

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Forms on Disk: Several software vendors offer workers’ compensation forms on disk and/or software packages to manage claims. Click here to view a list of those software vendors. Microsoft Word versions of selected forms are also available. See forms list below for forms available in Microsoft Word.

Microsoft® Word Versions of Forms: There are Microsoft Word document and document template versions—with form fields inserted—of Forms 17, 18, 19, 25C, 25N, 25T, 51, 60, 61, 62, 63, MSC4, and MSC5 and the Workers’ Compensation Nurses Section Referral Form. If you need a Microsoft Word version of any other form—which will not have form fields inserted—please e-mail Robert.McDowell@ic.nc.gov and specify the form(s) that you need. Note: If you do not know how to insert form fields in Microsoft Word documents, you will find the instructions in your Microsoft Word Help text.  Just press F1, type in forms, and press Enter.

Printed Copies of NCIC Forms: To obtain printed copies of the new forms, write the N.C. Industrial Commission, 4340 Mail Service Center, Raleigh, NC 27699-4340, call (919) 807-2527, or e-mail Carolyn Wall at Carolyn.Wall@ic.nc.gov. Orders require prepayment. Please call or e-mail to obtain current prices and to confirm quantities available.

PDF Versions of NCIC Forms: You may print and fill out the following PDF (Portable Document Format) versions of Industrial Commission forms, and submit them to the commission in lieu of the NCIC’s preprinted forms. To view or print these PDF files, you must download and install a copy of the Adobe^® Acrobat^® Reader. Click the button below to obtain your FREE copy of Adobe^® Acrobat^® Reader. (NOTE: Please pay close attention to this software’s installation instructions and licensing agreement.)

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Free Fillable PDF Versions of NCIC Forms: You may download a free set of fillable PDF (Portable Document Format) versions of selected N.C. Industrial Commission forms from the Interface Technologies home page: http://www.interfacetec.com/.

To download Interface Technologies’ free partial NCIC forms package, go to http://www.interfacetec.com/. Click Free Software. Then go to the Workers’ Compensation Forms section of that web page, and click North Carolina to start the downloading process. You may fill in these forms on your computer and print them and submit them to the Commission in lieu of the NCIC’s preprinted forms.

Workers’ Compensation Forms

All N.C. Industrial Commission forms that include the NCIC’s main telephone number were revised in February 2001 to reflect the NCIC’s new main telephone number. To view and download a form in PDF format, click the hypertext line at left.

• Form 17—N.C. Workers’ Compensation Notice to Injured Workers and Employers (revised 2/09).
  The Form 17 is also available in Microsoft Word as a document file.
   
  La Forma 17—Información Sobre Compensación Laboral y Instrucciones para Patronos y Empleados (revisada 3/04).

• Form 18—Notice of Accident to Employer and Claim of Employee, Representative, or Dependent for Workers’ Compensation Benefits (G.S. §97-22 through G.S. §97-24) (revised 8/1/08).

NOTE 1: Click here for a Form 18 with Instructions (both in PDF format). These instructions were prepared by the Industrial Commission’s Workers’ Compensation Information Specialists Section (formerly the Ombudsman Section).

NOTE 2: Click here for a Microsoft Word Form 18 Document Template.

NOTE 3: Click here for an interactive version of Form 18 created by FirstReport Software (revised 8/1/08).

La Forma 18—Aviso de Accidente y Reclamo del Empleado, Representante ó Dependiente (G.S. §97-22 Hasta G.S. §24) (revisada 8/08). Informacion General Del Formulario 18 (revisada 8/08).

• Form 18B—Claim by Employee, Representative, or Dependent for Lung Disease, Including Asbestosis, Silicosis, and Byssinosis (G.S. §97-53) (revised 5/02).

• 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) (revised 2/01).

• Form 19—Employer’s Report of Employee’s Injury or Occupational Disease to the Industrial Commission (revised 8/1/08).
  The Form 19 is also available in Microsoft Word as a document file or a template file. 

Click here for an updated interactive version of Form 19 created by FirstReport Software (revised 8/1/08)

• Form 21—Agreement for Compensation for Disability (G.S. §97-82) (revised 10/06). Spanish version: Forma 21—Acuerdo de Remuneración por Incapacitación (G.S. §97-82) (traducido 3/07).

• Form 22—Statement of Days Worked and Earnings of Injured Employee (revised 10/06).

• Form 24—Application to Terminate or Suspend Payment of Compensation (G.S. §97-18.1) (revised 2/01). Note: Important Notice Regarding Filing of Forms 24 (Executive Secretary Tracey H. Weaver’s April 15, 2005 memo).

• Form 25C—Authorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment (revised 1/04). Note 1: Please fill out this form completely; sign it; and mail it to the rehabilitation professional named on the form. Note 2: There is also a Spanish version of the Form 25C: 

NOTE:  A Microsoft Word Form 25C Document File with Form Fields is now available.

Forma 25C—Permiso al Especialista de Rehabilitación Médica para Obtener Reportes Corrientes del Tratamiento Médico (revisada 6/04). Resumen De Las Reglas Que Rigen El Uso De Los Profesionales De Rehabilitación En Los Casos De Compensación Laboral Para Los Trabajadores Lesionados (revisada 1/09).
 

• Form 25N—Notice to the Commission of Assignment of Rehabilitation Professional (revised 8/04). Note 1:  A Microsoft Word Form 25N Document Template is now available. Note 2: 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: Gina Bunn; mail it Workers’ Compensation Nurses Section, N.C. Industrial Commission, 4341 Mail Service Center, Raleigh, NC 27699-4341, ATTN: Gina Bunn or convert the Form 25N to a Microsoft Word or PDF (Portable Document Format) e-mail attachment and e-mail it to 25n@ic.nc.gov.
   
• Form 25P—Itemized Statement of Charges for Drugs (revised 2/01).

• Form 25R—Evaluation for Permanent Impairment (revised 8/1/08).

• Form 25T—Itemized Statement of Charges for Travel (revised 1/09). Click here for fillable Microsoft Word version of Form 25T, with form fields inserted.

• Form 26—Supplemental Agreement as to Payment of Compensation (G.S. §97-82) (revised 8/1/08).

• Form 26A—Employer’s Admission of Employee’s Right to Permanent Partial Disability (G.S. §97-31) (revised 8/1/08).
   
• Form 26D—Agreement for Payment of Unpaid Compensation in Unrelated Death Cases (G.S. §97-37) (revised 2/01).

• Form 28—Return to Work Report (revised 2/01).

• Form 28B—Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation  (revised 11/03).

• Form 28C—Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid Pursuant to a Compromise Settlement Agreement (new 11/03).

• Form 28T—Notice of Termination of Compensation by Reason of Trial Return to Work (G.S. §97-18.1(b) and G.S. §97-32.1) (revised 2/01).

• Form 28U—Employee’s Request That Compensation Be Reinstated After Unsuccessful Trial Return to Work (G.S. §97-32.1) (revised 6/02).

• Form 29—Supplemental Report for Fatal Accidents (Form 19, employer’s report of employee’s injury to the Industrial Commission, must also be submitted in every case) (revised 2/01).

• Form 30—Agreement for Compensation for Death (revised 11/01).

• Form 30A—Notice of Award (revised 8/08).
   
• Form 30D—Award Approving Agreement for Compensation for Death (revised 11/01).

• Form 31—Application for Lump Sum Award (revised 9/01).

• Form 33—Request That Claim Be Assigned for Hearing (revised 2/01). Spanish version: Forma 33—Petición que la Demanda sea Asignada a una Audiencia (traducido 9/04).

• Form 33R—Response to Request That Claim Be Assigned for Hearing (revised 2/01).

• Form 36—Subpoena for Witness (revised 11/05).

• Form 42—Application for Appointment of Guardian Ad Litem (revised 2/01).

• Form 44—Application for Review (revised 4/08).

• Form 51—Annual Consolidated Fiscal Report of “Medical Only” or “Lost Time” Cases (revised 6/05). To view instructions for filling out Form 51, click here.

NOTE:  A Microsoft Word Form 51 Document Template is now available.

• Form 60—Employer’s Admission of Employee’s Right to Compensation Pursuant to G.S. §97-18(b) (revised 8/1/08).

NOTE:  A Microsoft Word Form 60 Document Template is now available.

• Form 61—Denial of Workers’ Compensation Claim (G.S. §97-18(c) and G.S. §97-18(d)) (revised 10/06).

NOTE:  A Microsoft Word Form 61 Document Template is now available.

• Form 62—Notice of Reinstatement or Modification of Compensation (G.S. §97-32.1 and G.S. §97-18(b)) (revised 10/06).

NOTE:  A Microsoft Word Form 62 Document Template is now available.

• Form 63—Notice to Employee of Payment of Compensation Without Prejudice (G.S. §97-18(d)) or Payment of Medical Compensation Without Prejudice (G.S. §97-2(19) and G.S. §97-25) (revised 8/1/08).

NOTE:  A Microsoft Word Form 63 Document Template is now available.

• Form 87A —Affidavit of Accrued Arrearages (G.S. §97-87(d)).

• Form 87C —Certificate of Accrued Arrearages or Certified Accounting of Award (G.S. §97-87) (revised 7/08).

• Form 87S —Statement of Accrued Arrearages (G.S. §97-87(c )(1)) (revised 7/08).

• Form 90—Report of Earnings (revised 2/01).

• Compromise Settlement Agreement Checklist (revised 2/05).
   
• Form for Certification of Payment of Compromise Settlement Agreement Fee (added 9/09).

• Indigent Appeal Form—Petition to Appeal as an Indigent Person (added 11/01).

• Workers’ Compensation Nurses Section Referral Form (revised 11/07). Note 1:  A Microsoft Word Workers’ Compensation Nurses Section Referral Form Document Template is now available. Note 2: Please fax this completed and signed form to (919) 715-8231, ATTN: Gina Bunn; or mail it to Workers’ Compensation Nurses Section, N.C. Industrial Commission, 4341 Mail Service Center, Raleigh, NC 27699-4341, ATTN: Gina Bunn.

Death Benefits Forms

To view and download a form in PDF format, click the hypertext line at left.

• Claim Form—Claim for Benefits Under the Law Enforcement Officers’, Firemen’s, Rescue Squad Workers’ and Civil Air Patrol Members’ Death Benefits Act, G.S. §143-166, et seq. (revised 6/05).
   
• Form 42—Application for Appointment of Guardian Ad Litem (revised 2/01).

Erroneous Conviction Form

To view and download a form in PDF format, click the hypertext line at left.

• Form EC100—Claimant’s Petition for Compensation Pursuant to N.C. Gen. Stat. §148-82 et seq. (revised 2/01).

Mediation Forms

To view and download a form in PDF format, click the hypertext line at left.

• Form MSC2—Petition for Order Referring Case to Mediated Settlement Conference (revised 4/08).

• Form MSC4—Designation of Mediator (revised 9/01).

NOTE:  A revised Microsoft Word MSC4 Document Template is now available.

• Form MSC5—Report of Mediator (revised 9/01).

NOTE:  A revised Microsoft Word MSC5 Document Template is now available.

• Form MSC6—Mediator’s Declaration of Interest and Qualifications (revised 6/05).

• Form MSC7—Report of Evaluator (revised 9/01).
   
• Form MSC8—Mediated Settlement Agreement (issued 12/08).
  NOTICE: The Form MSC8 is in the process of being revised, and a draft of the revised form will be posted here in the near future. If you have any questions, comments, or suggestions with regard to the draft revised form once it has been posted, please e-mail Deputy Commissioner John C. Schafer at John.Schafer@ic.nc.gov.

Tort Award Forms

To view and download a form in PDF format, click the hypertext line at left.

• Form No. T-1—Claim for Damages Under Tort Claims Act, G.S. §143-291 et seq. (revised 2/01).

• Form No. T-3—Release of Tort Claim Under G.S. §143-291 et seq. (revised 5/02).

• Form No. T-44—Application for Review.

• Indigent Petition-to-Sue Form—Petition to Sue as an Indigent Pursuant to G.S. §1-110 (revised 11/01).

• Indigent Appeal Form—Petition to Appeal as an Indigent Person (added 11/01).

Workers’ Compensation Medical Status Questionnaire

To view and download a form in PDF format, click the hypertext line at left.

• Workers’ Compensation Medical Status Questionnaire.