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Form |
Description |
| form19.pdf | Employer’s Report of Employee’s Injury or Occupational Disease to the Industrial Commission - 8/12 |
| form18.pdf | Notice of Accident to Employer and Claim of Employee, Representative, or Dependent for Workers' Compensation Benefits - 8/1/08 |
| forma18.pdf | Aviso De Accidente Y Reclamo Del Empeado, Representante Ó Dependiente - 8/08 |
| form17.pdf | POSTER - N.C. Workers’ Compensation Notice to Injured Workers and Employers - 5/10 |
| form17s.pdf | POSTER - Información Sobre Compensación Laboral y Instrucciones para Patronos y Empleados - 3/04 |
| form18b.pdf | Claim by Employee, Representative, or Dependent for Lung Disease, Including Asbestosis, Silicosis, and Byssinosis - 5/02 |
| form18m.pdf | Employee's Application for Additional Medical Compensation - 2/01 (Applicable to Injuries by Accident or Occupational Illness on or After July 5, 1994) |
| form21.pdf | Agreement for Compensation for Disability - 10/06 (Filing fee $250.00) |
| form21s.pdf | Acuerdo de Remuneración por Incapacitación - 3/07 |
| form22.pdf | Statement of Days Worked and Earnings of Injured Employee - 10/06 |
| form23.pdf | Application To Reinstate Payment Of Disability Compensation 8/11 |
| form24.pdf | Application to Terminate or Suspend Payment of Compensation - 2/01 (Filing fee $175.00) |
| form25c.pdf | Authorization for Rehabilitation Professional to Obtain Medical Records of Current Treatment - 1/04 |
| form25cs.pdf | Permiso al Especialista de Rehabilitación Médica para Obtener Reportes Corrientes del Tratamiento Médico - 4/06 |
| form25n.pdf | Notice to the Commission of Assignment of Rehabilitation Professional - 5/12 |
| form25p.pdf | Itemized Statement of Charges for Drugs - 2/01 |
| form25r.pdf | Evaluation for Permanent Impairment - 8/1/08 |
| form25t.pdf | Itemized Statement of Charges for Travel - 1/13 |
| form26a.pdf | Employers Admission Of Employee’s Right To Permanent Partial Disability - 8/1/08 (Filing fee $250.00) |
| form26.pdf | Supplemental Agreement as to Payment of Compensation - 8/1/08 (Filing fee $250.00) |
| form26d.pdf | Agreement for Payment of Unpaid Compensation in Unrelated Death Cases - 2/01 |
| form26i.pdf | Medical Provider Dispute Resolution Questionnaire - N/D |
| form28.pdf | Return to Work Report - 2/01 |
| form28b.pdf | Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation - 11/03 |
| form28c.pdf | Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid Pursuant to a Compromise Settlement Agreement - 11/03 |
| form28t.pdf | Notice of Termination of Compensation by Reason of Trial Return to Work - 2/01 |
| form28u.pdf | Employee's Request That Compensation Be Reinstated After Unsuccessful Trial Return to Work - 6/02 |
| form29.pdf | Supplementary Report for Fatal Accidents - 2/01 (First Report of Accident must also be made in every case). |
| form30.pdf | Agreement for Compensation for Death - 5/12 |
| form30a.pdf | Notice of Award - 8/08 |
| form30d.pdf | Award Approving Agreement for Compensation for Death - 5/12 |
| form31.pdf | Application for Lump Sum Award Agreement for Compensation for Death - 2/01 |
| form33.pdf | Request That Claim Be Assigned for Hearing - 2/01 |
| form33i.pdf | Intervenor\'s Request That Claim Be Assigned For Hearing - N/D |
| form33r.pdf | Response to Request That Claim Be Assigned for Hearing - 2/01 |
| form33s.pdf | Petición que la Demanda sea Asignada a una Audiencia - 9/04 |
| form36.pdf | Subpoena for Witness - 10/05 |
| form42.pdf | Application for Appointment of Guardian Ad Litem - 2/01 |
| form44.pdf | Application for Review - 3/11 |
| form51.pdf | Annual Consolidated Fiscal Report of "Medical Only" or "Lost Time" Cases - 6/10 |
| form51in.pdf | Instructions for filling out Form 51 - N/D |
| form60.pdf | Employer's Admission of Employee's Right to Compensation Pursuant to - 8/1/08 |
| form61.pdf | Denial of Workers' Compensation Claim - 10/06 |
| form62.pdf | Notice of Reinstatement or Modification of Compensation - 10/06 |
| form63.pdf | Notice to Employee of Payment of Compensation Without Prejudice - 8/1/08 |
| form87a.pdf | Affidavit of Accrued Arrearages - 3/03 |
| form87c.pdf | Certificate of Accrued Arrearages or Certified Accounting of Award - 7/08 |
| form87s.pdf | Statement of Accrued Arrearages - 7/08 |
| form90.pdf | Report of Earnings - 2/01 |
| frmec100.pdf | Claimant's Petition for Compensation - 8/97 |
| msc1.pdf | Consent Order For Mediated Settlement Conference 4/11 |
| msc2.pdf | Petition for Order Referring Case to Mediated Settlement Conference - 4/08 |
| msc3.pdf | Order For Mediated Settlement Conference 4/11 |
| msc4.pdf | Designation of Mediator - 4/11 |
| msc5.pdf | Report of Mediator - 4/11 |
| msc6.pdf | Mediator's Declaration of Interest and Qualifications - 1/13 |
| msc7.pdf | Report of Evaluator - 4/11 |
| msc8.pdf | Mediated Settlement Agreement - 5/11 |
| msc9.pdf | Mediated Settlement Agreement - Alternative Form 4/11 |
| formt-1.pdf | Claim for Damages Under Tort Claims Act, - 2/01 |
| formt-3.pdf | Release of Tort Claim - 5/02 |
| formt-44.pdf | Application for Review - 6/00 |
| csachecklist.pdf | Health Benefit Plans and Medical Costs Internal Checklist for the Review of Compromise Settlement Agreements - 7/11 |
| cert_pay.pdf | Certification of Payment of Processing Fee For Compromise Settlement Agreements - N/D |
| indigentappeal.pdf | Petition to Appeal as an Indigent - N/D |
| indigentsue.pdf | Petition to Sue as an Indigent - N/D |
| nurseref.pdf | Workers' Compensation Nurses Section Referral Form - 11/12 |
| deathben.pdf | Claim for Benefits Under the Law Enforcement Officers', Firemen's, Rescue Squad Workers' and Civil Air Patrol Members' Death Benefits Act - 6/05 |
| wcmsques.pdf | Workers’ Compensation Medical Status Questionnaire - N/D |
| EFT_authorization.pdf | ManageAR EFT Payment Account Set-Up Form ND (added 4/11) |