Free Form 26 - North Carolina


File Size: 30.9 kB
Pages: 2
File Format: PDF
State: North Carolina
Category: Workers Compensation
Author: Mcdowelr
Word Count: 688 Words, 4,551 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ic.nc.gov/ncic/pages/form26.pdf

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Preview Form 26
North Carolina Industrial Commission

IC File # Emp. Code # Carrier Code # Carrier File #

SUPPLEMENTAL AGREEMENT AS TO PAYMENT OF COMPENSATION (G.S. ยง97-82)
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

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

WE, THE UNDERSIGNED, DO HEREBY AGREE AND STIPULATE AS FOLLOWS:
1. Date of injury: 2. The employee returned to work / was rated on was reduced / was increased on (date), at a weekly wage of $ . , from $ per week per week .

3. The employee became totally disabled on 4. Employee's average weekly wage to $ beginning per week. , and continuing for

5. The employer and carrier/administrator hereby undertake to pay compensation to the employee at the rate of $ weeks. The type of disability compensation is 6. State any further matters agreed upon, including disfigurement or temporary partial disability: 7. The date of this agreement is .

NAME OF EMPLOYER

SIGNATURE

TITLE

NAME OF CARRIER/ADMINISTRATOR

SIGNATURE

TITLE

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 ADDRESS SIGNATURE OF EMPLOYEE'S ATTORNEY
ADDRESS

Check box if no attorney retained.

NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING AGREEMENT IS HEREBY APPROVED: CLAIMS EXAMINER ATTORNEY'S FEE APPROVED DATE

FORM 26 8/1/08 PAGE 1 OF 2

FORM 26

SELF-INSURED EMPLOYER OR CARRIER MAIL TO: NCIC - CLAIMS ADMINISTRATION 4335 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE: (919) 807-2500 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 5 JULY 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS
If your injury occurred before 5 July 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 5 JULY 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS
If your injury occurred on or after 5 July 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
This form is to be used only to supplement Form 21, Agreement for Compensation for Disability (G.S. 97-82), or an award in cases in which subsequent conditions require a modification of a former agreement or award. The employee must be provided a copy of the form 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) 6888349.

FORM 26 8/1/08 PAGE 2 OF 2

FORM 26

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