Free Microsoft Word - form21.DOC - North Carolina


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State: North Carolina
Category: Workers Compensation
Author: Mcdowelr
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North Carolina Industrial Commission
IC File #

AGREEMENT FOR COMPENSATION FOR DISABILITY (G.S. 97-82)
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address

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

(

)
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

1. 2. 3. 4. 5. 6. 7. 8. 9.

WE, THE UNDERSIGNED, DO HEREBY AGREE AND STIPULATE AS FOLLOWS: All parties hereto are subject to and bound by the provisions of the Workers' Compensation Act and is the carrier/administrator for the employer. The employee sustained an injury by accident or the employee contracted an occupational disease arising out of and in the course of employment on or by . The injury by accident or occupational disease resulted in the following injuries:
The employee was/ was not paid for the entire day when the injury occurred. The average weekly wage of the employee at the time of the injury, including overtime and all allowances, was $ , subject to verification unless otherwise agreed upon in line 9 below. Disability resulting from the injury or occupational disease began on The employer and carrier/administrator hereby undertake to pay compensation to the employee at the rate of $ per week beginning , and continuing for The employee has / has not returned to work for on , at an average weekly wage of $ . State any further matters agreed upon, including disfigurement, permanent partial, or temporary partial disability: . Check . Date of first payment: is is not attached. Amount: Title Title

. weeks.

10. If applicable, the Second Injury Fund Assessment is $ 11. The date of this agreement is Name Of Employer Name Of Carrier / Administrator

Signature Signature

By signing I enter into this agreement and certify that I have read the "Important Notices to Employee" printed on the reverse side of this form. Signature of Employee Signature of Employee's Attorney Address Address NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING AGREEMENT IS HEREBY APPROVED: CHECK BOX IF NO ATTORNEY RETAINED. CHECK BOX IF EMPLOYEE IS IN MANAGED CARE. CLAIMS EXAMINER DATE ___________________________________________ ATTORNEY'S FEE APPROVED

SELF-INSURED EMPLOYER OR CARRIER, MAIL TO: FORM 21 10/2006 PAGE 1 OF 2

FORM 21

NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH, NC 27699-4335 TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/

IMPORTANT NOTICE TO EMPLOYEE CLAIMING ADDITIONAL WEEKLY CHECKS OR LUMP SUM PAYMENTS Once your compensation checks have been stopped, if you claim further compensation, you must notify the Industrial Commission in writing within two years from the date of receipt of your last compensation check or your rights to these benefits may be lost.

IMPORTANT NOTICE TO EMPLOYEE INJURED BEFORE JULY 5,1994 CLAIMING ADDITIONAL MEDICAL BENEFITS If your injury occurred before July 5, 1994, you are entitled to medical compensation as long as it is reasonably necessary, related to your workers' compensation case, and authorized by the carrier or the Industrial Commission. IMPORTANT NOTICE TO EMPLOYEE INJURED ON OR AFTER JULY 5, 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS If your injury occurred on or after July 5, 1994, your right to future medical compensation will depend on several factors. Your right to payment of future medical compensation will terminate two years after your employer or carrier/administrator last pays any medical compensation or other compensation, whichever occurs last. If you think you will need future medical compensation, you must apply to the Industrial Commission in writing within two years, or your right to these benefits may be lost. To apply you may also use Industrial Commission Form 18M.

IMPORTANT NOTICE TO EMPLOYER The employee must be provided a copy when the agreement is signed by the employee. Failure to file Form 28B, Report Of Compensation And Medical Compensation Paid, within 16 days after last payment pursuant to this agreement may subject the employer or carrier/administrator to a penalty. Pursuant to Rule 501, within 20 days after receipt of the agreement executed by the employee, the employer or carrier/administrator must submit the agreement to the Industrial Commission, or show good cause for not submitting the agreement.

NEED ASSISTANCE ? If you have questions or need help and you do not have an attorney, you may contact the Industrial Commission at (800) 688-8349.

SELF-INSURED EMPLOYER OR CARRIER, MAIL TO: FORM 21 10/2006 PAGE 2 OF 2

FORM 21

NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH, NC 27699-4335 TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/