Free Microsoft Word - form18.dot - North Carolina


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State: North Carolina
Category: Workers Compensation
Author: Mcdowelr
Word Count: 449 Words, 2,886 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ic.nc.gov/ncic/pages/form18.pdf

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North Carolina Industrial Commission IC File #

NOTICE OF ACCIDENT TO EMPLOYER AND CLAIM OF EMPLOYEE, REPRESENTATIVE, OR DEPENDENT (G.S. 97-22 THROUGH 24)
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Employer FEIN
The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence.

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

)

-

Telephone Number State Zip

( -

) -

M
Sex

( F

) / /

State Zip

Home Telephone Social Security Number

Work Telephone Date of Birth

(

)

-

(

)

-

Carrier's Telephone Number

Carrier's Fax Number

EMPLOYEE This form must be filed with the Industrial Commission within two years of the date of injury or occupational disease or your claim may be barred. Notice shall be given to the employer immediately after the accident or as soon as practicable and within 30 days. (This form should also be used for occupational disease claims; however, for asbestosis, silicosis and byssinosis, Form 18B is to be used.)
Notice is hereby given, as required by law, that the above-named employee sustained an injury or contracted an occupational disease, described as follows:
Time of Injury

on

/

/

at
City and County

. Describe the injury or occupational disease,

Date (required)

including the specific body part involved (e.g., right hand, left hand) Describe how the injury or occupational disease occurred:

Occupation when injured: Nature of employer's business: Number of days out of work due to injury: Medical treatment received? Yes No Weekly wage: $ Number of hours worked per day:

Days worked per week:

NOTE: If employee is unable to sign this form, another may sign for him. This form should be typed or printed by hand in black ink, if possible. Employee should retain one signed copy of this notice, mail one signed copy to the Industrial Commission at the address below, and provide one signed copy to employer.
(
Signature of (Check One) Employee, Attorney, Representative, or Dependent Address City State Zip

)

-

Telephone Number

/

/

Date Completed

EMPLOYER: This notice is being sent to you in compliance with requirements of the North Carolina Workers' Compensation Act, in order that the medical services prescribed by the Act may be obtained; and, if disability extends beyond 7 days duration, or if death ensues, compensation may be paid according to law.

FOR IC USE ONLY

MAIL TO: NCIC - CLAIMS ADMINISTRATION
4335 MAIL SERVICE CENTER

FORM 18 8/1/08 PAGE 1 OF 1

RESEARCHER: ______ CC: _____________ EC: _____________ DATA ENTRY: ______

FORM 18

RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/