Common Workers’ Compensation Forms in North Carolina

When pursuing a workers’ compensation claim in North Carolina, you will be required to complete several forms. The various forms ensure that the North Carolina Industrial Commission, which administers the workers’ compensation insurance system, has the relevant information from injured workers making claims for benefits.

Below, we discuss some of the most important workers’ compensation forms in North Carolina. If you work with a Hardison & Cochran workers’ compensation lawyer in North Carolina, we will make sure that all of the necessary forms are completed and submitted properly to support your claim.

If you or someone you love has been injured on the job or developed an occupational disease and you have questions about the workers’ compensation benefits available to injured employees in North Carolina, contact Hardison & Cochran now. Our law firm can help you with the claims process and work to secure all the workers’ compensation benefits available by law.

Contact us or at (800) 434-8399 to schedule a free consultation to discuss your legal options.

10 Most Often Used Workers’ Compensation Forms in North Carolina

Listed below are ten workers’ compensation forms that are widely used in workers’ compensation cases in North Carolina. You may encounter one or more of them if you are injured in a workplace accident and have a claim.

An experienced workers’ compensation lawyer at Hardison & Cochran can review the details of your workplace accident and help you understand which forms must be completed to seek medical compensation, temporary disability payments, and benefits.

Keep a copy of any form you submit.

• Form 18: Notice Of Accident To Employer And Claim Of Employee, Representative, Or Dependent. Your workers’ compensation claim begins with Form 18. When completed, it contains information to identify you, your employer, and their workers’ comp insurance carrier; general information about what happened to you; and your weekly wages and work hours. (You are not required to provide your employer’s insurance company information when completing Form 18 if you do not have that information. You may find it with the Insurance Coverage Search System.)

Submitting Form 18 establishes a legal claim of injury on your behalf. By submitting a copy of Form 18 to your employer within 30 days of your injury or diagnosis, you provide the required written notice to your employer. Form 18 must be filed with the Industrial Commission within two years of the date of a workplace injury or occupational disease diagnosis.

• Form 19: Employer’s Report Of Employee’s Injury Or Occupational Disease To The Industrial Commission. This is the first report of injury (FROI) that an employer should submit when an employee has a claim. The injured employee does not have to complete this form. Your employer should give you a copy of this completed form and a blank Form 18 for you to complete and submit.

Form 19 requires information to identify you, your employer, and the employer’s workers’ comp insurance carrier; general information about what happened to you; the cause and nature of your injury; and information to identify the employer’s OSHA Form 301: Injury and Illness Incident Report, which they must also file.

• Form 21: Agreement for Compensation for Disability. You and your employer will sign Form 21 if you come to an agreement on what you should be paid for your workplace injury, but you need to keep your claim open. It states how much the injured employee will be paid each week and for how long. When these payments have stopped, an employee who is still unable to return to work has two years to file a claim for further compensation from their employer.
• Form 22: Statement of Days Worked & Earnings of Employee. This form requires an accounting of wages paid to the injured employee over the year prior to their injury. It is used to determine the compensation rate if there is a disagreement about earnings or if the Industrial Commission requests it. Form 22 must be filed in all cases resulting in death unless the employer stipulates that the deceased worker’s family should receive the maximum compensation rate.

• Form 25P: Itemized Statement of Charges for Drugs. Workers’ compensation medical benefits include paying for prescribed medication the injured employee requires. This form asks for dates, pharmacy, drug name and prescription number, physician’s name, and cost. Medication costs may be reimbursed to the employee or drug store.

• Form 25T: Itemized Statement of Travel Charges. Workers’ compensation reimburses for certain travel costs related to necessary medical care, such as seeing specialists for treatment or obtaining prescribed medication. As of January 1, 2023, workers’ compensation recipients are entitled to travel reimbursement of $0.655 per mile, provided they travel 20 miles or more roundtrip. The form allows listing travel expenses and states reimbursement rates for overnight lodging and meal costs.
• Form 28: Return To Work Report. The employer files this form to notify the Industrial Commission that the employee has returned to work and that disability compensation should end. This applies to a full-recovery return to work. For a trial work period, the employer would file Form 28T, Notice Of Termination Of Compensation By Reason Of Trial Return To Work. Workers’ comp law allows a trial return to work for up to nine months. If the trial return to work is unsuccessful, full workers’ comp benefits resume immediately. During a trial return to work, an employee may be entitled to partial disability compensation if they earn less than before being injured because of their on-the-job injury.

If the trial return to work is unsuccessful, the employee would complete Form 28U, Employee’s Request That Compensation Be Reinstated After Unsuccessful Trial Return.

• Form 33: Request That Claim Be Assigned for Hearing. If your workers’ compensation claim has been denied, you may appeal by requesting a hearing before the North Carolina Industrial Commission. This form requires you to certify that you are ready for a hearing, describe the disagreement that needs to be heard, and identify witnesses you will call to testify. Either the injured worker or the employer may file an appeal. Once a hearing is requested, a mediation session will be scheduled.

In North Carolina, mediation of a workers’ compensation claim is mandatory before appearing in front of an Industrial Commission Deputy Commissioner. If you have already been through mediation, you would indicate that on Form 33.

You can find forms normally used by workers’ comp claimants on NC Industrial Commission website. Each form comes with instructions for completing it. They are also available in Spanish.

Consult an Experienced North Carolina Workers’ Comp Attorney

Though you can pursue workers’ compensation benefits without a lawyer’s help, you will be at a disadvantage without legal guidance. An NC workers’ compensation lawyer can obtain medical records and ensure all the necessary forms are completed on time. We can help you to work through problems that may arise in your case. It is essential to stay within the bounds of North Carolina’s complicated workers’ compensation laws to continue to receive benefits.

The workers’ compensation lawyers at Hardison & Cochran want to help you. Contact us today to learn more about our services during a free consultation. We serve injured workers across North Carolina, including those located in Raleigh, Cary, Durham, Wake County, Research Triangle Park, the Triangle, Fayetteville, Dunn, Southern Pines, Greensboro, the Triad, and Wilmington.