Free Form 33 - North Carolina


File Size: 27.8 kB
Pages: 2
File Format: PDF
State: North Carolina
Category: Workers Compensation
Author: Mcdowelr
Word Count: 448 Words, 2,748 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ic.nc.gov/ncic/pages/form33.pdf

Download Form 33 ( 27.8 kB)


Preview Form 33
North Carolina Industrial Commission
IC File #

REQUEST THAT CLAIM BE ASSIGNED FOR HEARING
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Carrier File# Employer FEIN

(
Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address

)
Telephone Number City State Zip

(

) M F

( /

)
City State Fax Number Zip

Home Telephone Social Security Number Sex

Work Telephone

/

(

)

(

)

Date of Birth

Carrier's Telephone Number

I,

, respectfully notify you that the above named parties have failed to reach an agreement

in regard to compensation, and I request a hearing. We have been unable to agree because (state reason with specificity): Employee believes he or she is entitled to the following workers' compensation benefits (check all that apply): Payment of compensation for days missed (give dates): Payment of medical expenses/treatment: Payment for permanent partial disability: Payment for permanent and total disability: Payment for scars: Other: Has claimant participated in mediation? Date of injury: City and county wherein injury occurred: Estimated length of hearing: Below is a list of names and addresses of all witnesses, including doctors, whose testimony is to be taken by the requesting party. Doctors outside the county of hearing are not required to attend this hearing. NAME ADDRESS Yes No Part of body:

MAIL TO:
FORM 33 2/01 PAGE 1 OF 2

FORM 33

NCIC - DOCKET SECTION 4336 MAIL SERVICE CENTER RALEIGH, NC 27699-4336 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/

When a date of hearing is set, I respectfully request the Commission to send me signed subpoenas for my witnesses. When I receive these subpoenas, I will deliver them to the Sheriff of the county or counties in which each witness resides so that the subpoenas may be served.

(Signature of party requesting hearing, or attorney)

(Title)

(Address: street and number, city, state and zip)

(Date of notice)

CERTIFICATION I, ,hereby certify that this case is ready for hearing. This case will be set in the county where the injury occurred unless good reason is shown for a different location. If you want the hearing in a different county, name the county below and your reason for that location.

(County)

(Reason for setting)

(Signature)

Note: A copy of this form must be sent to opposing parties. The original of this form must be sent to the Industrial Commission at the address below:

MAIL TO:
FORM 33 2/01 PAGE 2 OF 2

FORM 33

NCIC - DOCKET SECTION 4336 MAIL SERVICE CENTER RALEIGH, NC 27699-4336 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/