Fillable Printable N.C. Workers' Compensation Notice to Injured Workers and Employees - North Carolina

N.C. Workers' Compensation Notice to Injured Workers and Employees - North Carolina

FORM 17 Revised 11/2014

N.C. WORKERS’ COMPENSATION NOTICE TO INJURED WORKERS AND EMPLOYERS

All employees of this business, except specifically excluded executive officers, suffering work-related

injuries may be entitled to Workers’ Compensation benefits from the employer or its insurance carrier.

IF YOU HAVE A WORK-RELATED INJURY OR AN OCCUPATIONAL DISEASE

The Employee Should:

 Report the injury or occupational disease to the Employer immediately.

 Give written notice to the Employer w ithin 30 days.

 File a claim with the Industrial Commission on a Form 18 immediately, but no later than 2 years from injury date or occupational disease.

Give a copy to the Employer.

 If medical treatment and wage loss compensation are not promptly provided, call the insurance carrier/administrator or request a hearing

before the Industrial Commission using a Form 33 Request for Hearing. Commission forms are available at website www.ic.nc.gov or by

calling the Help Line.

 Your employer’s workers’ compensation insurance carrier is _______ __________________ __________________________________________.

 The insurance policy number is ____________________________________________________________ _______________________________.

 Your employer’s workers’ compensation insurance policy is valid from ____________ _____________ _ until ___________________________.

For assistance: Call the Industrial Commission HELP LINE—(800) 688-8349.

The Employer Should:

 Provide all necessary medical services to the Employee.

 Report the injury to the carrier/administrator and file a Form 19 Report of Injury within 5 days with the Industrial Commission, if the

Employee misses more than 1 day from work or if cumulative medical costs exceed $2,000.00.

 Give a copy of your completed Form 19 to the Employee along with a copy of a blank Form 18 Notice of Accident.

 Ensure that compensation is promptly paid as required under the Workers’ Compensation Act.

For assistance with Safety Education Training contact:

Director of Safety Education at (919) 807-2602 or [email protected]

NORTH CAROLINA INDUSTRIAL COMMISSION

4335 MAIL SERVICE CENTER

RALEIGH, NORTH CAROLINA 27699-4335

Website: www.ic.nc.gov

TO EMPLOYER: THIS FORM MUST BE PROMINENTLY POSTED IF YOU HAVE WORKERS’ COMPENSATION INSURANCE OR QUALIFY AS SELF-INSURED. (N.C. Gen. Stat. §97-93).