Free Form 18B - North Carolina

North Carolina Industrial Commission
IC File #

CLAIM BY EMPLOYEE, REPRESENTATIVE, OR DEPENDENT FOR BENEFITS FOR LUNG DISEASE
INCLUDING ASBESTOSIS, SILICOSIS, AND BYSSINOSIS (G.S. 97-53)
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Employer FEIN

M
Employee's Name Address City State Zip Social Security Number Sex

F

/

/

Date of Birth

If Employee is deceased, list Personal Representative Spouse's Name Name of Attorney if represented

(

)

(

)
Work Telephone

Employee's Home Telephone

PRINT OR TYPE ALL ANSWERS

Notice is hereby given, as required by law, that the above-named employee sustained an occupational disease caused by . exposure to: cotton dust ; silica ; asbestos ; or other substance and, if known, state substance: Date of diagnosis By: Dr. Attach diagnosing medical records. Employer-Defendants Attach additional pages if necessary
Employer Name: Address: City State Zip Telephone: ( ) Location of Job(s) Dates of Employment

Employer Name: Address: City State

Telephone: (

) Location of Job(s)

Dates of Employment

Zip

Employer Name: Address: City State

Telephone: (

) Location of Job(s)

Dates of Employment

Zip

Employer Name: Address: City State

Telephone: (

) Location of Job(s)

Dates of Employment

Zip

IT IS REQUIRED THAT BOTH PAGES OF THIS FORM BE COMPLETED IN ORDER TO PROCESS THIS CLAIM

FORM 18B 5/02 PAGE 1 OF 2

FORM 18B

MAIL TO: NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/

Employment History, Beginning With Most Recent Employment (Attach additional pages if necessary): Employer From / To: Employer's Type of Business Employee's Job Title

If you were exposed to the listed substance(s) while working for this employer, describe in detail the exposures:

Employer

From / To:

Employer's Type of Business

Employee's Job Title

If you were exposed to the listed substance(s) while working for this employer, describe in detail the exposures:

Employer

From / To:

Employer's Type of Business

Employee's Job Title

If you were exposed to the listed substance(s) while working for this employer, describe in detail the exposures:

List the names and addresses of all family physicians, treating physicians and hospitals that have provided medical services or treatment to you over a 20 year period prior to the filing of this claim.

Year

Name

Address (City)

Purpose for which treated (if known)

I hereby authorize the above named medical sources to disclose medical records (including images such as x-rays, CT scans, MRIs, sonograms, etc.) regarding my treatment, hospitalization, and/or outpatient care for any condition during the period(s) identified above to all parties (including insurance companies) or State agencies that may review my application for compensation. I also hereby authorize that a photocopy of this authorization be accepted with the same authority as this original. The information disclosed will be used in connection with my claim for benefits under the Workers' Compensation Act. I understand this authorization will automatically expire when my application for benefits is finally decided.
( Signature of (Check One) Employee, Attorney, Representative, or Dependent Address City State Zip ) Telephone Number

Date Completed

Employee should return original of this form to the Industrial Commission, furnish his/her employer with one signed copy, and retain a copy. FORM 18B 5/02 PAGE 2 OF 2

FORM 18B

MAIL TO: NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/