SUBCHAPTER 10L – INDUSTRIAL COMMISSION FORMS

 

SECTION .0100 – WORKERS’ COMPENSATION FORMS

 

04 NCAC 10L .0101          FORM 21 – AGREEMENT FOR COMPENSATION FOR DISABILITY

(a)  (Effective until July 1, 2015) The parties to a workers' compensation claim shall use the following Form 21, Agreement for Compensation for Disability, for agreements regarding disability and payment of compensation therefor pursuant to G.S. 97-29 and 97-30.  Additional issues agreed upon by the parties such as payment of compensation for permanent partial disability may also be included on the form.  This form is necessary to comply with Rule 04 NCAC 10A .0501, where applicable.  The Form 21, Agreement for Compensation for Disability, shall read as follows:

 

North Carolina Industrial Commission

Agreement for Compensation for Disability

(G.S. 97-82)

 

IC File # __________

Emp. Code # __________

Carrier Code # __________

Carrier File # __________

Employer FEIN __________

 

The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

 

____________________________________________________________

Employee's Name

____________________________________________________________

Address

____________________________________________________________

City                                   State               Zip

____________________________________________________________

Home Telephone                                                          Work Telephone

Social Security Number: _______ Sex: M     F  Date of Birth: _______

 

____________________________________________________________

Employer's Name                                                Telephone Number

____________________________________________________________

Employer's Address                                                   City    State     Zip

____________________________________________________________

Insurance Carrier

____________________________________________________________

Carrier's Address                                                       City    State     Zip

____________________________________________________________

Carrier's Telephone Number                                        Carrier's Fax Number

 

We, The Undersigned, Do Hereby Agree And Stipulate As Follows:

1.             All parties hereto are subject to and bound by the provisions of the Workers' Compensation Act and __________ is the carrier/administrator for the employer.

2.             The employee sustained an injury by accident or the employee contracted an occupational disease arising out of and in the course of employment on or by __________ .

3.             The injury by accident or occupational disease resulted in the following injuries: __________

________________________________________________________________________________.

4.             The employee was/ was not paid for the entire day when the injury occurred.

5.             The average weekly wage of the employee at the time of the injury, including overtime and all allowances, was $________, subject to verification unless otherwise agreed upon in Item 9 below.

6.             Disability resulting from the injury or occupational disease began on ________.

7.             The employer and carrier/administrator hereby undertake to pay compensation to the employee at the rate of $________ per week beginning ________, and continuing for ________ weeks.

8.             The employee has / has not returned to work for ________________________________

on ________________ , at an average weekly wage of $________.

9.             State any further matters agreed upon, including disfigurement, permanent partial, or temporary partial disability: ________________________________________________________________.

10.          If applicable, the Second Injury Fund Assessment is $________. Check is is not attached.

11.          The date of this agreement is ________. Date of first payment: ________ Amount: ________.

12.          IMPORTANT NOTICE TO EMPLOYEE: The Industrial Commission’s fee for processing this agreement is $300.00 to be paid in equal shares by the employee and the employer. You are not required to pay your portion of the fee in advance, and if your award is $3,000.00 or less, you are not responsible for any portion of the fee. If your award is more than $3,000.00, the employer shall deduct $150.00 from your award, unless you and your employer agree otherwise.

Check one of the boxes below if the award is more than $3,000.00:

The employer will deduct $150.00 from the amount to be paid pursuant to this agreement.

The employee and employer have agreed that the employer will pay the entire fee.

 

__________________________________________________________________________________

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 Pages 1 and 2 of this form.

__________________________________________________________________________________

Signature of Employee                                                                       Address

__________________________________________________________________________________

Signature of Employee's Attorney                                   Address

 

North Carolina Industrial Commission

The Foregoing Agreement Is Hereby Approved:

___________________________________________

Claims Examiner                                            Date

___________________________________________

Attorney's Fee Approved

 

Check Box If No Attorney Retained.

Check Box If Employee Is In Managed Care.

 

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 JULY 5, 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS

 

If your injury occurred before July 5, 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 JULY 5, 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS

If your injury occurred on or after July 5, 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, Employee’s Application for Additional Medical Compensation (G.S. 97-25.1), available at http://www.ic.nc.gov/forms.html.

 

IMPORTANT NOTICE TO EMPLOYER

 

The employee must be provided a copy when the agreement is signed by the employee. Pursuant to Rule 04 NCAC 10A .0501, 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 cause for not submitting the agreement.  The employer or carrier/administrator shall file a Form 28B, Report of Compensation and Medical Compensation Paid, within 16 days after the last payment made pursuant to this agreement or be subject to a penalty.

 

NEED ASSISTANCE?

 

If you have questions or need help and you do not have an attorney, you may contact the Industrial Commission at (800) 688-8349.

 

Form 21

11/2014

 

Self-Insured Employer or Carrier, Mail to:

NCIC - Claims Section

4335 Mail Service Center

Raleigh, NC 27699-4335

Telephone: (919) 807-2502

Helpline:  (800) 688-8349

Website: http://www.ic.nc.gov/

 

(a)  (Effective July 1, 2015) The parties to a workers' compensation claim shall use the following Form 21, Agreement for Compensation for Disability, for agreements regarding disability and payment of compensation therefor pursuant to G.S. 97-29 and 97-30.  Additional issues agreed upon by the parties such as payment of compensation for permanent partial disability may also be included on the form.  This form is necessary to comply with Rule 04 NCAC 10A .0501, where applicable.  The Form 21, Agreement for Compensation for Disability, shall read as follows:

 

North Carolina Industrial Commission

Agreement for Compensation for Disability

(G.S. 97-82)

 

IC File # __________

Emp. Code # __________

Carrier Code # __________

Carrier File # __________

Employer FEIN __________

 

The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

 

____________________________________________________________

Employee's Name

____________________________________________________________

Address

____________________________________________________________

City                                   State               Zip

____________________________________________________________

Home Telephone                                                          Work Telephone

Social Security Number: _______ Sex: M     F  Date of Birth: _______

 

____________________________________________________________

Employer's Name                                                Telephone Number

____________________________________________________________

Employer's Address                                                   City    State     Zip

____________________________________________________________

Insurance Carrier

____________________________________________________________

Carrier's Address                                                       City    State     Zip

____________________________________________________________

Carrier's Telephone Number                                        Carrier's Fax Number

 

We, The Undersigned, Do Hereby Agree And Stipulate As Follows:

1.             All parties hereto are subject to and bound by the provisions of the Workers' Compensation Act and __________ is the carrier/administrator for the employer.

2.             The employee sustained an injury by accident or the employee contracted an occupational disease arising out of and in the course of employment on or by __________.

3.             The injury by accident or occupational disease resulted in the following injuries: __________

________________________________________________________________________________.

4.             The employee was/ was not paid for the entire day when the injury occurred.

5.             The average weekly wage of the employee at the time of the injury, including overtime and all allowances, was $________, subject to verification unless otherwise agreed upon in Item 9 below.

6.             Disability resulting from the injury or occupational disease began on ________.

7.             The employer and carrier/administrator hereby undertake to pay compensation to the employee at the rate of $________ per week beginning ________, and continuing for ________ weeks.

8.             The employee has / has not returned to work for ________________________________

on ________________ , at an average weekly wage of $________.

9.             State any further matters agreed upon, including disfigurement, permanent partial, or temporary partial disability: ________________________________________________________________.

10.          If applicable, the Second Injury Fund Assessment is $________. Check is is not attached.

11.          The date of this agreement is ________. Date of first payment: ________ Amount: ________.

 

 

__________________________________________________________________________________

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 Page 2 of this form.

__________________________________________________________________________________

Signature of Employee                                                                       Address

__________________________________________________________________________________

Signature of Employee's Attorney                                   Address

 

North Carolina Industrial Commission

The Foregoing Agreement Is Hereby Approved:

___________________________________________

Claims Examiner                                            Date

___________________________________________

Attorney's Fee Approved

 

Check Box If No Attorney Retained.

Check Box If Employee Is In Managed Care.

 

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 JULY 5, 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS

 

If your injury occurred before July 5, 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 JULY 5, 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS

If your injury occurred on or after July 5, 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, Employee’s Application for Additional Medical Compensation (G.S. 97-25.1), available at http://www.ic.nc.gov/forms.html.

 

IMPORTANT NOTICE TO EMPLOYER

 

The employee must be provided a copy when the agreement is signed by the employee. Pursuant to Rule 04 NCAC 10A .0501, 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 cause for not submitting the agreement.  The employer or carrier/administrator shall file a Form 28B, Report of Compensation and Medical Compensation Paid, within 16 days after the last payment made pursuant to this agreement or be subject to a penalty.

 

NEED ASSISTANCE?

 

If you have questions or need help and you do not have an attorney, you may contact the Industrial Commission at (800) 688-8349.

 

Form 21

7/2015

 

Self-Insured Employer or Carrier, Mail to:

NCIC - Claims Section

4335 Mail Service Center

Raleigh, NC 27699-4335

Telephone: (919) 807-2502

Helpline:  (800) 688-8349

Website: http://www.ic.nc.gov/

 

(b) The copy of the form described in Paragraph (a) of this Rule can be accessed at http://www.ic.nc.gov/forms/form21.pdf.  The form may be reproduced only in the format available at http://www.ic.nc.gov/forms/form21.pdf  and may not be altered or amended in any way.

 

History Note:        Authority G.S. 97-73; 97-80(a); 97-81(a); 97-82; S.L. 2014-77;

Eff. November 1, 2014.