Free Form 17 Blue - North Carolina

FORM 17

Revised 2/2009

N.C. WORKERS' COMPENSATION NOTICE TO INJURED WORKERS AND EMPLOYERS
All employees of this business, except specifically excluded executive officers, suffering work-related injuries may be entitled to Workers' Compensation benefits from the employer or its insurance carrier.

IF YOU HAVE A WORK-RELATED INJURY OR AN OCCUPATIONAL DISEASE The Employee Should:
· · · · Report the injury or occupational disease to the Employer immediately. Give written notice to the Employer within 30 days. File a claim with the Industrial Commission on a Form 18 immediately, but no later than 2 years from injury date or occupational disease. Give a copy to the Employer. If medical treatment and wage loss compensation are not promptly provided, call the insurance carrier/administrator or request a hearing before the Industrial Commission using a Form 33 Request for Hearing. Commission forms are available at website www.ic.nc.gov or by calling the Help Line.

For assistance: Call the Industrial Commission HELP LINE--(800) 688-8349. The Employer Should:
· · · · Provide all necessary medical services to the Employee. Report the injury to the carrier/administrator and file a Form 19 Report of Injury within 5 days with the Industrial Commission, if the Employee misses more than 1 day from work or if cumulative medical costs exceed $2,000.00. Give a copy of your completed Form 19 to the Employee along with a copy of a blank Form 18 Notice of Accident. Ensure that compensation is promptly paid as required under the Workers' Compensation Act.

For assistance with Safety Education Training, at no cost, contact: Director of Safety Education at (919) 807-2602 or [email protected]
NORTH CAROLINA INDUSTRIAL COMMISSION 4335 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4335 Website:

www.ic.nc.gov

TO EMPLOYER: THIS FORM MUST BE PROMINENTLY POSTED IF YOU HAVE WORKERS' COMPENSATION INSURANCE OR QUALIFY AS SELF-INSURED. (N.C. Gen. Stat. §97-93).