North Carolina Industrial Commission                                                                                                                           IC File #  
 EMPLOYER’S REPORT OF  MPLOYEEE                                                          S ’NJURYI            OR                                            Emp. FEIN       
 O  CCUPATIONAL DISEASE TO THE  NDUSTRIAL I                                                                      OMMISSIONC                               Carrier FEIN       
  To the Employer: 
  A copy of this Form 19 accompanied by a blank Form 18 must be given to the employee. It does                                                              Carrier File #  
  not satisfy the employee’s obligation to file a claim. The filing of this report is required by law.                                                                    
  This form MUST be transmitted to the Industrial Commission through your Insurance Carrier.                                                            
                                                                                                                                                        
  To the Employee:                                                                                                                                      
  This Form 19 is not your claim for workers’ compensation benefits. To make a claim, you must complete                                                The I.C. File # is the unique identifier for 
                                                                                                                                                       this injury. It will be provided by return 
  and sign the enclosed Form 18 and mail it to Claims Administration, N.C. Industrial Commission, 1235                                                 letter and is to be referenced in all future 
  Mail Service Center, Raleigh, NC 27699-1235 within two years of the date of your injury or last payment                                              correspondence. 
                                                                                                                                                        
  of medical compensation. For occupational diseases, the claim must be filed within two years of the date                                              
  of disability or the date your doctor told you that you have a work-related disease, whichever is later. 
 The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act 
  
                                                                                                                                                                  (   )    -     
 Employee’s Name                                                                                          Employer’s Name                                                                               Telephone Number 
                                                                                                                                                                                                                            
 Address                                                                                                  Employer’s Address                           City            State  Zip 
                                                                                                                                                               
                          City                               State                                 Zip    Insurance Carrier                            Policy Number 
 (   )    -                                                  (   )    -                                                                                                                                                     
 Home Telephone                                              Work Telephone                               Carrier’s Address                            City            State  Zip 
    -  -                                       M          F    /  /                                       (   )    -                                   (   )    -         
 Social Security Number                        Sex                        Date of Birth                   Carrier’s Telephone Number                   Fax Number 
   Employer                      1.  Give nature of employer’s business        
                                 2.  Location of plant where injury occurred                                    
   Time                              County                          Department                                                           State if employer’s premises            
   And                           3.  Date of injury        /  /        4.  Day of week                                               Hour of day       :            A.M.         P.M. 
   Place                         5.  Was employee paid for entire day                                         6.  Date disability began    /  /                               
                                 7.  Date you or the supervisor first knew of injury    /  /                                  8.  Name of supervisor               
                                 9.  Occupation when injured        
   Person                       10.  (a) Time employed by you                                                       (b) Wages per hour       $                  
   Injured                      11.  (a) No. hours worked per day                            (b) Wages per day                $             (c) No. of days worked per week   
                                     (d) Avg. weekly wages w/ overtime                     $                           (e) If board, lodging, fuel or other advantages were 
                                          furnished in addition to wages, estimated value per day, week or month.                               $      per              
                                12.  Describe fully how injury occurred and what employee was doing when injured:       
   Cause  
   And Nature 
   Of Injury 
                                                                      (Statement made without prejudice and without vouching for correctness of information) 
                                13.  List all injuries and specify body part involved (e.g. right hand or left hand):                                

                                14.  Date & hour returned to work    /  /   at   :    .M.                                    15.  If so, at what wages  $          per            
                                16.  At what occupation                                                             17.  Employee’s salary continued in full?                                                               
                                18.  Was employee treated by a physician                                      
   Fatal Cases                  19.  Has injured employee died                             20.  If so, give date of death (Submit Form 29)               /  /      
   Employer name                                                                                                                       Date Completed    /  /   
   Signed by                                                                                                       Official Title       
   
  OSHA 301 Information: 
   Case Number from Log:                       Date Hired:        Time Employee began work on date of incident:                              If off-site medical treatment provided, 
                                                     /  /                                    :                 A.M.      P.M.                answer entire next line. 
   Name of facility:                                              Address:  Street/City/Zip/Telephone                                           ER visit?          Overnight stay? 
                                                                                                                                                 Yes     No             Yes    No 
   Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to 
   the extent possible while the information is being used for occupational safety and health purposes. 
                                      FOR ICU  SE  NLYO                                                      SELF-INSURED     EMPLOYER  OR   CARRIER,   F   ILE  AS    FROI  VIA  EDI: 
                                                                                                             HTTP://WWW.IC.   NC.GOV/EDIFORM 19.HTML 
                                     RESEARCHER:______                                                        
 FORM 19                             CC:_____________                                                        UNINSURED EMPLOYERS OR  UNG L   ISEASE D  LAIMS C     : 
                                     EC:_____________ 
 1/2020                              DATA ENTRY:______       FORM19                                          E-MAIL TO :FORMS     @IC.NC.GOV OR MAIL TO :NCIC-C    LAIMS  ECTIONS                                        , 
 PAGE  1OF 2                                                                                                 1235M  AIL SERVICE  ENTER  C ALEIGH ,R  ,NC27699-1235 
                                                                                                             MAIN TELEPHONE :(919)807-2500      H    ELPLINE  : (800)688-8349 
                                                                                                             WEBSITE  :HTTP://    WWW.IC. NC.GOV/ 

             IMPORTANT INFORMATION FOR EMPLOYER 
                                                         
Employer must furnish a copy of this form, as completed, to the employee or the employee’s representative when submitted 
to the Insurance Carrier or Claims Administrator for transmission to the Commission.  Every question must be answered. This 
Form 19 must be transmitted to the Commission through your insurance carrier/claims administrator, and is required by law 
 to be filed within 5 days after knowledge of accident. Employer must also give employee a blank Form 18. 
 
             IMPORTANT INFORMATION FOR EMPLOYEE 
 
                                                        Reporting an Injury 
 
  If you do not agree with the description or time of the accident given on this form, you should make a written report of injury 
to the employer within thirty (30) days of the injury. 
 
                                                        Making A Claim 
 
  To be sure you have filed a claim, complete a Form 18, Notice of Accident, within two years of the date of the injury and 
send a copy to the Industrial Commission and to your employer.  The employer is required by law to file this Form 19, but the 
filing of the Form 19 does not satisfy the employee’s obligation to file a claim.  The employee must file a Form 18 even though 
the employer may be paying compensation without an agreement, or the Commission may have opened a file on this claim.  A 
claim may also be made by a letter describing the date and nature of the injury or occupational disease.  This letter must be 
signed and sent to the Industrial Commission and to your employer. 
 
  FOR ASSISTANCE OR TO OBTAIN A FORM 18 FROM THE INDUSTRIAL COMMISSION, YOU MAY CALL (800) 688-8349 
 
             USE YOUR I.C. FILE NUMBER (IF KNOWN) OR SOCIAL SECURITY NUMBER ON 
              ALL FUTURE CORRESPONDENCE WITH THE COMMISSION 
 
              [SPANISH TRANSLATION] 
                                                         
             INFORMACIÓN IMPORTANTE PARA LOS EMPLEADOS 
                                                         
             Reporte de una Lesión (Reporting an Injury) 
                                                         
  Si usted no está de acuerdo con la descripción o la hora del accidente que aparece en el formulario, debe hacer un reporte 
de la lesión por escrito y dárselo a su empleador dentro de un período de treinta (30) días a partir de la fecha de la lesión. 
   
             Cómo Presentar una Reclamación (Making a Claim) 
 
  Para ceriorarse de que ha presentado una reclamación, complete el Formulario 18 Notificación de Accidente dentro de un 
período de dos años a partir de la fecha de la lesión y envíe una copia a la Comisión Industrial y una copia a su empleador.  Por 
ley, el empleador debe presentar el Formulario 19, sin embargo, el presentar el Formulario 19 no cumple con la obligación que 
tiene el empleado de presentar una reclamación.  El empleado debe presentar el Formulario 18 aunque el empleador esté 
pagando compensación sin tener un acuerdo o si la Comisión ha creado un expediente con respecto a esta reclamación.  
También se puede presentar una reclamación por medio de una carta explicando la fecha y la naturaleza de la lesión o la 
enfermedad ocupacional.  Esta carta se debe firmar y enviar a la Comisión Industrial así como al empleador. 
   
       PARA RECIBIR ASISTENCIA O PARA OBTENER EL FORMULARIO 18 DE LA COMISIÓN INDUSTRIAL, USTED 
              PUEDE HABLAR AL (800) 688-8349 
                                                          
            EN TODA LA CORRESPONDENCIA QUE ENVÍE A LA COMISIÓN INDUSTRIAL POR FAVOR ESCRIBA  
             EL NÚMERO DE CASO DESIGNADO POR LA COMISIÓN [I.C. FILE NUMBER]  (SI LO SABE)  
              O SU NÚMERO DE SEGURO SOCIAL. 

                                                         SELF-INSURED       EMPLOYER  OR        CARRIER , FILE  AS FROI   VIA  EDI: 
                                                         HTTP://WWW.IC.     NC.GOV/EDIFORM      19.HTML 
                                                          
FORM 19                                                  UNINSURED EMPLOYERS OR  UNG L          ISEASE D LAIMS C : 
1/2020       FORM19                                      E-MAIL TO: FORMS@IC.       NC.GOV   OR MAIL TO: NCIC-C    LAIMS  ECTIONS , 
PAGE  2OF 2                                              1235M         AIL SERVICE  ENTER  C ALEIGH ,R ,NC27699-1235 
                                                         MAIN TELEPHONE : (919)807-2500              HELPLINE:  (800)688-8349 
                                                         WEBSITE:  HTTP://WWW.IC.     NC.GOV    /