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 and printed for submission electronically, per Rule 11 NCAC 23A .0108.
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.
For Employers
Click Here for a list of forms used primarily by Employers 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.
The Electronic Form 18 may not be used in cases involving more than one employer.
OR
Standard Form 18 with Instructions
This Form 18 may be filed with the Commission as instructed on the bottom of the form.
(Click here for the Spanish Form 18.)
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 (printable PDF)
Request That Claim Be Assigned for Hearing
(Click here for the Spanish Form 33.)
Form 42
Application for Appointment of Guardian Ad Litem
This form is used when the claimant is a minor or incompetent person and has no general or testamentary Guardian. In civil actions in North Carolina when any of the parties is a minor 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.
Employer Forms
Form 19
This is the first report of injury (FROI) that an employer submits when an employee has a claim. Effective June 1, 2014, all first reports of injury (FROI) for injuries occurring after April 1, 1997 must be filed electronically via EDI unless they qualify for one of two exceptions. The only exceptions to electronic filing of FROI's are claims (1) in which a Form 18 was previously filed and a six-character alphanumeric number has already been assigned, or (2) for an occupational disease in which a Form 18B has already been filed.
If the claim meets one of the two exceptions listed above, use the Standard Form 19 with Instructions below.
Standard Form 19 with Instructions
If the claim meets one of the exceptions outlined above, this PDF version of the Form 19 may be completed and filed via EDFP on the NCIC Online Services Center. A non-insured employer without representation may file the Form 19 using any method described on the form.
Form 17
N.C. Workers' Compensation Notice to Injured Workers and Employers. This form MUST be prominently posted if you have Worker's Compensation Insurance or qualify as Self-Insured. (N.C. Gen. Stat. §97-93). (Click here for the Spanish Form 17.)
Form 18
Employers are required to provide this form whenever a report of injury or occupational disease has been received from an employee. This form MUST be filled out completely by the employee and submitted to the Industrial Commission in addition to the Form 19.
Standard Form 18 With Instructions
This Form 18 may be downloaded, printed, filled out and mailed into the NC Industrial Commission. Please read the attached instructions for required information and the mailing address.
(Click here for the Spanish Form 18.)
Executive Secretary Forms
Form 18M
Employee's Application for Additional Medical Compensation (G.S. §97-25.1)
Form 23
Application to Reinstate Payment of Disability Compensation (G.S. §97-18(k))
Form 24
Application to Terminate or Suspend Payment of 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
Nursing & Medical Rehabilitation Forms
Referral Form
Medical Rehabilitation Nurses Section Referral Form. Please use this form to request assistance from the Medical Rehabilitation Nurses Section. Fill out the form completely, making sure to include the I.C. Number for the claim, if possible; and e-mail the completed form to rehab.referrals@ic.nc.gov.
The completed form can be mailed to us at:
NC Industrial Commission
1236
Mail Service Center
Raleigh, NC 27699-1236
ATTN: Medical Rehabilitation Nurses
Form 25C
Authorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment. Please fill out the form completely, sign it, and mail it to the rehabilitation professional named on the form.Click here for the Spanish Form 25C
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 submit to the Commission as directed on the form.
