Workers' Compensation Rules
of the N.C. Industrial Commission

ARTICLE I. ADMINISTRATION

1. The Industrial Commission will supply, on request, forms identified by number and title as follows: [Note: To view or print PDF versions of these forms, you must download and install a free Adobe^® Acrobat^® Reader.] 

   Form 17—Workers’ Compensation Notice

   Form 18—Notice of Accident to Employer and Claim of Employee or His Personal Representative or Dependents (N.C. Gen. Stat. §§97-22, 97-23, and 97-24)

   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 the Industrial Commission

   Form 21—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—Application to Terminate or Suspend Payment of Compensation Pursuant to N.C. Gen. Stat. §97-18.1

   Form 25C—Authorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment

   Form 25N—Notice to the Industrial Commission of Assignment of Rehabilitation Professional

   Form 25P—Itemized Statement of Charges for Drugs

   Form 25R—Evaluation for Permanent Impairment

   Form 25T—Itemized Statement of Charges for Travel

   Form UB-92—Hospital Bill

   Form 26—Supplemental Agreement as to Payment of Compensation Pursuant to N.C. Gen. Stat. §97-82

   Form 26A—Employer’s Admission of Employee’s Right to Permanent Partial Disability Pursuant to N.C. Gen. Stat. §97-31

   Form 26D—Agreement for Compensation Under N.C. Gen. Stat. §97-37

   Form 28—Return to Work Report

   Form 28B—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—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 90—Report of Earnings

   Form IZ-510—Medical Bill Analysis Used for Approval and Reduction of Medical Bills

   Form MSC2—Petition for Order Referring Case to Mediated Settlement Conference

   Form MSC4—Designation of Mediator

   Form MSC5—Report of Mediator

   Form MSC6—Mediator’s Declaration of Interest and Qualifications

   Form MSC7—Report of Evaluator

   Form MSC8—Mediated Settlement Agreement

   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 reproduce approved forms for their own use, provided:
    
   1. No statement, question, or information blank contained on the approved Industrial Commission’s form is omitted from the substituted form.
       
   2. 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: [Note: PDF versions of these forms will eventually be listed below. To view or print PDF versions of these forms, you must download and install a free Adobe^® Acrobat^® Reader.]
    

   Form I—Order for Third Party Recovery Distribution per N.C. Gen. Stat. §97-10.2

   Form II—Order Approving Compromise Settlement Agreement (admitted liability, medical paid) and Third Party Distribution

   Form III—Order for Approving Compromise Settlement Agreements (admitted liability, medical paid)
    

4. Copies of rules, forms, and Industrial Commission Minutes can be obtained by contacting the Administrator’s Office of the Industrial Commission, 4340 Mail Service Center, Raleigh, NC 27699-4340.

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