04 NCAC 10L .0102          FORM 26 – SUPPLEMENTAL AGREEMENT AS TO PAYMENT OF COMPENSATION

(a)  (Effective until July 1, 2015) If the parties to a workers' compensation claim have previously entered into an approved agreement on a Form 21, Agreement for Compensation for Disability, or a Form 26A, Employer's Admission of Employee's Right to Permanent Partial Disability, they shall use the following Form 26, Supplemental Agreement as to Payment of Compensation, for agreements regarding subsequent additional disability and payment of compensation 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 26, Supplemental Agreement as to Payment of Compensation, shall read as follows:

 

North Carolina Industrial Commission

Supplemental Agreement as to Payment      

of Compensation (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.             Date of injury: __________

2.             The employee returned to work / was rated on __________  (date), at a weekly wage of $__________.

3.             The employee became totally disabled on __________.

4.             Employee's average weekly wage was reduced /  was increased on __________, from $__________ per week to $__________ per week.

5.             The employer and carrier/administrator hereby undertake to pay compensation to the employee at the rate of $__________ per week.

Beginning __________, and continuing for__________ weeks.  The type of disability compensation is

________________________________________________________________________________.

6.             State any further matters agreed upon, including disfigurement or temporary partial disability:

________________________________________________________________________________.

7.             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.

 

8.             The date of this agreement is __________.

__________________________________________________________________________________

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

 

Check box if no attorney retained.

 

North Carolina Industrial Commission

The Foregoing Agreement Is Hereby Approved:

__________________________________________________________________________________

Claims Examiner                                                               Date

__________________________________________________________________________________

Attorney's fee approved

 

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

 

This form shall be used only to supplement Form 21, Agreement for Compensation for Disability (G.S. 97-82), or an award in cases in which subsequent conditions require a modification of a former agreement or award.  The employee must be provided a copy of the form 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 26

11/2014

 

Self-Insured Employer or Carrier Mail to:

NCIC - Claims Administration

4335 Mail Service Center

Raleigh, North Carolina 27699-4335

Main Telephone: (919) 807-2500

Helpline:  (800) 688-8349

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

 

(a)  (Effective July 1, 2015) If the parties to a workers' compensation claim have previously entered into an approved agreement on a Form 21, Agreement for Compensation for Disability, or a Form 26A, Employer's Admission of Employee’s Right to Permanent Partial Disability, they shall use the following Form 26, Supplemental Agreement as to Payment of Compensation, for agreements regarding subsequent additional disability and payment of compensation 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 26, Supplemental Agreement as to Payment of Compensation, shall read as follows:

 

North Carolina Industrial Commission

Supplemental Agreement as to Payment

of Compensation (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.             Date of injury: __________.

2.             The employee returned to work / was rated on __________  (date), at a weekly wage of $__________.

3.             The employee became totally disabled on __________.

4.             Employee's average weekly wage was reduced /  was increased on __________, from $__________ per week to $__________ per week.

5.             The employer and carrier/administrator hereby undertake to pay compensation to the employee at the rate of $__________ per week.

Beginning __________, and continuing for__________ weeks.  The type of disability compensation is

________________________________________________________________________________.

6.             State any further matters agreed upon, including disfigurement or temporary partial disability:

________________________________________________________________________________.

 

 

7.             The date of this agreement is __________.

__________________________________________________________________________________

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

 

Check box if no attorney retained.

 

North Carolina Industrial Commission

The Foregoing Agreement Is Hereby Approved:

__________________________________________________________________________________

Claims Examiner                                                               Date

__________________________________________________________________________________

Attorney's fee approved

 

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

 

This form shall be used only to supplement Form 21, Agreement for Compensation for Disability (G.S. 97-82), or an award in cases in which subsequent conditions require a modification of a former agreement or award.  The employee must be provided a copy of the form 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 26

7/2015

 

Self-Insured Employer or Carrier Mail to:

NCIC - Claims Administration

4335 Mail Service Center

Raleigh, North Carolina 27699-4335

Main Telephone: (919) 807-2500

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/form26.pdf.  The form may be reproduced only in the format available at http://www.ic.nc.gov/forms/form26.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.