| NORTH CAROLINA INDUSTRIAL COMMISSION Help Line: ( 800) 688-8349, ( 919) 716-1700, or infospec@ic. nc. gov Fraud and Insurance Compliance Hotline: ( 888) 891-4895 or fraudcomplaints@ic. nc. gov La Página en Español About Us Contact Sitemap Login NC@Your Service You are here: Home NCIC Forms Home Latest News Breaking News & Important Announcements Safety Education & Training Injured Workers Injured Workers Page Claims Forms Claimant FAQs Employers Who Must Carry Workers' Comp Insurance Employers Page Claim Processing Forms Employer FAQs e-File Carriers Carriers Page Claims Forms Carrier FAQs e-File Attorneys Attorneys Page Full Commission Calendars Deputy Commissioner Calendars Court Decisions Rating Guide Commission Rules Attorney FAQs e-File Medical Providers Medical Providers Page Claims Forms Medical FAQs FAQs FAQs PAGE Common FAQs Executive Secretary FAQs Insurance Carriers FAQs Mediation FAQs Medical Fees FAQs Medical Rehabilitation FAQs Sections Claims Administration Clerk's Office Compliance Criminal Investigations & Employee Classification Deputy Commissioners Executive Secretary Full Commission Information Specialists IT Section Mediation Medical Fees Medical Rehabilitation Nurses Safety Education & Training e-File Electronic Document Filing Portal Form 19 via EDI Pay Invoice Links NCIC Bulletin Contacts Forms Hearing Calendars Information Specialists N. C. Court Decisions NCIC Offices News Pay Online Searchable Databases WC Administrators Website Archives NCIC Forms 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. NEW! Electronic Form 18. 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 NEW! Electronic Form 33. ( 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. NEW! Electronic Form 18. 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. Forms News Workers' Comp Documents Must Be Filed Electronically In accordance with Rule 11 NCAC 23A . 0108 , all documents filed with the Industrial Commission in workers' compensation cases must be submitted electronically. ( Employees without legal representation are not required to file electronically.) The Commission has updated all of its forms to facilitate e-filing. Click here to access the Electronic Document Filing Portal ( EDFP) for instructions on how to upload documents to the EDFP and how to pay Industrial Commission invoices online. Forms List Specialty Forms Form 17 , N. C. Workers' Comp Notice to Injured Workers & Employers ( Spanish Form 17 ) Forms by Number Form 17 , Workers' Comp. Notice Workplace Poster ( Spanish Form 17 ) Form 18 , Notice of Accident With Instructions ( Spanish Form 18 ) NEW! Electronic Form 18. Form 18B , Claim by Employee for Lung Disease, Asbestos, etc. Form 18M , Req. for Additional Medical Compensation Form 19 , Employer's Report of Injury to the NCIC Form 21 , Agreement for Compensation for Disability Form 22 , Statement of Days Worked & Earnings of Employee Form 23 , Application to Reinstate Payment of Disability Compensation Form 24 , Application to Terminate or Suspend Payment of Compensation Form 25C , Authorization for Rehab Professional to Obtain Medical Records of Current Treatment ( Spanish Form 25C ) Form 25N , Notice of Assignment of Rehabilitation Professional Form 25P , Itemized Statement of Charges for Drugs Form 25PR , Request for Preauthorization of Medical Treatment Form 25R , Evaluation for Permanent Impairment Form 25T , Itemized Statement of Travel Charges Form 26 , Supplemental Agreement as to Payment of Compensation Form 26A , Employer's Admission of Employee's Right to Permanent Partial Disability ( Spanish Form 26A ) Form 26D , Agreement for Payment of Unpaid Compensation in Unrelated Death Cases Form 26I , Medical Provider Dispute Resolution Questionnaire 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 28C , Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid Pursuant to a Compromise Settlement Agreement Form 28T , Notice of Termination of Compensation by Reason of Trial Return to Work Form 28U , Employee's Request That Compensation Be Reinstated After Unsuccessful Trial Return to Work Form 29 , Supplemental Report to Form 19 for Fatal Accidents Form 30 , Agreement for Compensation for Death Form 30A , Notice of Award Form 30D , Award Approving Agreement for Compensation for Death Form 31 , Application for Lump Sum Award Form 33 , Request That Claim Be Assigned for Hearing ( Spanish Form 33 ) NEW! Electronic Form 33. Form 33I , Intervenor's Request That Claim be Assigned for Hearing Form 33R , Response to Request That Claim Be Assigned for Hearing Form 36 , Subpoena for Witness Form 42 , Application for Appointment of Guardian Ad Litem Form 44 , Application for Review Form 51 , Annual Consolidated Fiscal Report of "Medical Only" or "Lost Time" Cases Form 51 , Instructions Form 60 , Employer's Admission of Employee's Right to Compensation Form 61 , Denial of Workers' Compensation Claim Form 62 , Notice of Reinstatement or Modification of Compensation Form 63 , Notice to Employee of Payment of Compensation Without Prejudice or Payment of Medical Compensation Without Prejudice Form 87A , Affidavit of Accrued Arrearages Form 87C , Certificate of Accrued Arrearages or Certified Accounting of Award Form 87S , Statement of Accrued Arrearages Form 90 , Report of Earnings ( Spanish Form 90 ) Form EC100 Erroneous Conviction - Claimant's Petition for Compensation Form MSC1 , Consent Order for Mediated Settlement Conference Form MSC2 , Petition for Order Referring Case to Mediated Settlement Conference Form MSC3 , Order for 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 | NORTH CAROLINA INDUSTRIAL COMMISSION Help Line: ( 800) 688-8349, ( 919) 716-1700, or infospec@ic. nc. gov Fraud and Insurance Compliance Hotline: ( 888) 891-4895 or fraudcomplaints@ic. nc. gov La Página en Español About Us Contact Sitemap Login NC@Your Service You are here: Home NCIC Forms Home Latest News Breaking News & Important Announcements Safety Education & Training Injured Workers Injured Workers Page Claims Forms Claimant FAQs Employers Who Must Carry Workers' Comp Insurance Employers Page Claim Processing Forms Employer FAQs e-File Carriers Carriers Page Claims Forms Carrier FAQs e-File Attorneys Attorneys Page Full Commission Calendars Deputy Commissioner Calendars Court Decisions Rating Guide Commission Rules Attorney FAQs e-File Medical Providers Medical Providers Page Claims Forms Medical FAQs FAQs FAQs PAGE Common FAQs Executive Secretary FAQs Insurance Carriers FAQs Mediation FAQs Medical Fees FAQs Medical Rehabilitation FAQs Sections Claims Administration Clerk's Office Compliance Criminal Investigations & Employee Classification Deputy Commissioners Executive Secretary Full Commission Information Specialists IT Section Mediation Medical Fees Medical Rehabilitation Nurses Safety Education & Training e-File Electronic Document Filing Portal Form 19 via EDI Pay Invoice Links NCIC Bulletin Contacts Forms Hearing Calendars Information Specialists N. C. Court Decisions NCIC Offices News Pay Online Searchable Databases WC Administrators Website Archives NCIC Forms 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. NEW! Electronic Form 18. 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 NEW! Electronic Form 33. ( 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. NEW! Electronic Form 18. 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. Forms News Workers' Comp Documents Must Be Filed Electronically In accordance with Rule 11 NCAC 23A . 0108 , all documents filed with the Industrial Commission in workers' compensation cases must be submitted electronically. ( Employees without legal representation are not required to file electronically.) The Commission has updated all of its forms to facilitate e-filing. Click here to access the Electronic Document Filing Portal ( EDFP) for instructions on how to upload documents to the EDFP and how to pay Industrial Commission invoices online. Forms List Specialty Forms Form 17 , N. C. Workers' Comp Notice to Injured Workers & Employers ( Spanish Form 17 ) Forms by Number Form 17 , Workers' Comp. Notice Workplace Poster ( Spanish Form 17 ) Form 18 , Notice of Accident With Instructions ( Spanish Form 18 ) NEW! Electronic Form 18. Form 18B , Claim by Employee for Lung Disease, Asbestos, etc. Form 18M , Req. for Additional Medical Compensation Form 19 , Employer's Report of Injury to the NCIC Form 21 , Agreement for Compensation for Disability Form 22 , Statement of Days Worked & Earnings of Employee Form 23 , Application to Reinstate Payment of Disability Compensation Form 24 , Application to Terminate or Suspend Payment of Compensation Form 25C , Authorization for Rehab Professional to Obtain Medical Records of Current Treatment ( Spanish Form 25C ) Form 25N , Notice of Assignment of Rehabilitation Professional Form 25P , Itemized Statement of Charges for Drugs Form 25PR , Request for Preauthorization of Medical Treatment Form 25R , Evaluation for Permanent Impairment Form 25T , Itemized Statement of Travel Charges Form 26 , Supplemental Agreement as to Payment of Compensation Form 26A , Employer's Admission of Employee's Right to Permanent Partial Disability ( Spanish Form 26A ) Form 26D , Agreement for Payment of Unpaid Compensation in Unrelated Death Cases Form 26I , Medical Provider Dispute Resolution Questionnaire 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 28C , Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid Pursuant to a Compromise Settlement Agreement Form 28T , Notice of Termination of Compensation by Reason of Trial Return to Work Form 28U , Employee's Request That Compensation Be Reinstated After Unsuccessful Trial Return to Work Form 29 , Supplemental Report to Form 19 for Fatal Accidents Form 30 , Agreement for Compensation for Death Form 30A , Notice of Award Form 30D , Award Approving Agreement for Compensation for Death Form 31 , Application for Lump Sum Award Form 33 , Request That Claim Be Assigned for Hearing ( Spanish Form 33 ) NEW! Electronic Form 33. Form 33I , Intervenor's Request That Claim be Assigned for Hearing Form 33R , Response to Request That Claim Be Assigned for Hearing Form 36 , Subpoena for Witness Form 42 , Application for Appointment of Guardian Ad Litem Form 44 , Application for Review Form 51 , Annual Consolidated Fiscal Report of "Medical Only" or "Lost Time" Cases Form 51 , Instructions Form 60 , Employer's Admission of Employee's Right to Compensation Form 61 , Denial of Workers' Compensation Claim Form 62 , Notice of Reinstatement or Modification of Compensation Form 63 , Notice to Employee of Payment of Compensation Without Prejudice or Payment of Medical Compensation Without Prejudice Form 87A , Affidavit of Accrued Arrearages Form 87C , Certificate of Accrued Arrearages or Certified Accounting of Award Form 87S , Statement of Accrued Arrearages Form 90 , Report of Earnings ( Spanish Form 90 ) Form EC100 Erroneous Conviction - Claimant's Petition for Compensation Form MSC1 , Consent Order for Mediated Settlement Conference Form MSC2 , Petition for Order Referring Case to Mediated Settlement Conference Form MSC3 , Order for 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 |