Free Form 28U - North Carolina

North Carolina Industrial Commission

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

EMPLOYEE'S REQUEST THAT COMPENSATION BE REINSTATED AFTER UNSUCCESSFUL TRIAL RETURN TO WORK (G.S. 97-32.1)
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

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Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address

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Telephone Number City State Zip

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City State Fax Number Zip

Home Telephone Social Security Number Sex

Work Telephone

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Date of Birth

Carrier's Telephone Number

SECTION A. EMPLOYEE: COMPLETE AND MAIL TO EMPLOYER AND CARRIER/ADMINISTRATOR, AND TO THE INDUSTRIAL COMMISSION AT THE ADDRESS BELOW: 1. I request that my total disability compensation be resumed immediately. I had a trial return to work with (name of employer) from (date first worked) until (date last worked). The date of my injury by accident or the date of disability from my occupational disease was 2. Explain in detail the reasons you are no longer working: 3. The employee MUST obtain the following from an authorized treating physician: TREATING PHYSICIAN'S STATEMENT This is to certify that the employee is unable to continue the trial return to work due to the employee's injury for which compensation has been paid. My medical specialty is:
SIGNATURE OF AUTHORIZED TREATING PHYSICIAN ADDRESS CITY PRINTED NAME STATE DATE ZIP

IF RETURN TO WORK WAS WITH THE EMPLOYER FROM WHOM YOU HAVE RECEIVED WORKERS' COMPENSATION, SIGN HERE AND DO NOT COMPLETE THE REMAINDER OF THIS FORM. IF RETURN TO WORK WAS WITH A DIFFERENT EMPLOYER, COMPLETE SECTION B BELOW. SIGNATURE OF EMPLOYEE DATE

SECTION B. EMPLOYEE'S RELEASE OF EMPLOYMENT INFORMATION I hereby request and authorize my last employer,
(Name and address of last employer)

to release to my prior employer and carrier/administrator listed above, or their attorney of record, the following information relating to my trial return to work: first and last date worked, total wages earned, and the reasons this employee is no longer so employed.
READ BEFORE SIGNING SIGNATURE OF EMPLOYEE DATE SEND A COPY OF THIS FORM TO THE EMPLOYER AND CARRIER/ADMINISTRATOR FROM WHOM YOU WERE RECEIVING WORKERS' COMPENSATION. SEND THE ORIGINAL TO THE INDUSTRIAL COMMISSION AT THE ADDRESS BELOW.

FORM 28U 6/02 PAGE 1 OF 1

FORM 28U

MAIL TO: OFFICE OF THE EXECUTIVE SECRETARY 4333 MAIL SERVICE CENTER RALEIGH, NC 27699-4333 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/