ARTICLE IX
FRAUD
Rule 901
CHECK ENDORSEMENT
If a self-insured employer, carrier or third party administrator places "check endorsement" language on the back of an employee's check, the following language ( or similar language approved by the Industrial Commission) shall be used:By endorsing this check, I certify that I have not worked for or earned wages from any business or individual during the period covered by this check, or that I have reported any earnings to the employer/carrier paying me workers' compensation benefits. I understand that making a false statement by endorsing this benefit check may result in civil or criminal penalties.
Rule 902
NOTICE
A self-insured employer, carrier or third party administrator shall not use check endorsement language on the back of an employee's workers' compensation benefit check unless the employee has been provided the following Notice sent by certified mail return receipt requested:
Notice to Employee Receiving Workers' Compensation Benefits
This NOTICE is intended to advise you of important information you need to know if you are receiving workers' compensation benefits.
Please TAKE NOTICE of the following:
(1) When you are receiving weekly workers' compensation benefits, you must report any earnings you receive to the insurance company (or employer if the employer is self-insured) that is paying you the benefits. "Earnings" include any cash, wages or salary received from self-employment or from any employment other than the employment where you were injured. Earnings also include commissions, bonuses, and the cash value for all payments received in any form other than cash (e.g., a building custodian receiving a rent-free apartment). Commission bonuses, etc., earned before disability but received during the time you are also receiving workers' compensation benefits do not constitute earnings that must be reported.
(2) You must report any work in any business, even if the business lost money or if profits or income were reinvested or paid to others.
(3) Your endorsement on a benefit check or deposit of the check into an account is your statement that you believe that you are entitled to receive workers' compensation benefits. Your signature on a benefit check is a further affirmation that you have made no material false statement or concealed any material fact regarding your right to receive the benefit check.
(4) Making false statements for purpose of obtaining workers' compensation benefits may result in civil and criminal penalties.
Rule 903
REPORT OF EARNINGS
A self-insured employer, carrier or third party administrator may require the employee to complete a Form 90 Report of Earnings when reasonably necessary but not more than once per six month period. [Click here for a Portable Document Format version of Form 90, and click here for the free Adobe Acrobat Reader required to view and print PDF files.]
The Form 90 must be sent to the employee by certified mail, return receipt requested, and include a self-addressed stamped envelope for the return of the Form.
The employee shall complete and return the Form 90 Report of Earnings within 15 days after receipt of a Form 90. If the employee fails to complete and return the Report of Earnings within 30 days of receipt of the Form, the self-insured employer, carrier or third party administrator may file a Motion to suspend benefits with the Executive Secretary pursuant to the Form 24 procedure. The employer or carrier shall not suspend benefits without Commission approval. If benefits are suspended by the Commission for failure to complete and return a Form 90 Report of Earnings, benefits shall be immediately reinstated with back payment when the Report of Earnings is submitted by the employee and the employee's earnings report indicate continuing eligibility for partial or total disability compensation.
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N.C. Industrial Commission · 4319 Mail Service Center · Raleigh, NC 27699-4319
Main: (919) 733-4820 ·
Fax: (919) 715-0282 ·
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Internet Address: http://www.comp.state.nc.us/