North Carolina Industrial Commission IC File NOTICE OF ACCIDENT TO EMPLOYER AND CLAIM OF EMPLOYEE REPRESENTATIVE OR DEPENDENT G.S. 97-22 THROUGH 24 Emp. Code Carrier Code Employer FEIN The I. C. File is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence. The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act Employee s Name Address Employer s Address City State Zip M Social Security...
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To file a workers' compensation claim in North Carolina, you must complete a Form Eighteen, or Notice of Accident To Employer Form, and submit it to your employer within thirty days of your injury. The form also must be submitted to the North Carolina Industrial Commission within two years of the date of injury or occupational illness in order to establish a legal claim. If you suffered an occupational illness that resulted from asbestosis, silicosis, or byssinosis, you need to fill out a Form Eighteen B. To get started, you need a black ink pen. You also need to have the following information on-hand: employer's address, the employer's insurance carrier and address, and the number of days you missed work. If you don't know your employer's insurance carrier you can call the Industrial Commission's Claims Administration Section at eight hundred, six eight eight, eight three four nine or just leave those lines blank on the form. The top section of the form is where you will provide your name, address, phone number, Social Security number, gender, and date of birth. You will also provide your employer's name, phone number, and address and your employer's insurance carrier's name, policy number, phone number, and address. Below the contact information, write down the date, time, city, and county where your on-the-job injury or illness occurred. Then, describe the injury—with specifics—and how the injury happened. In this section, you should document if your medical treatment, your work hours and wages, and the number of days you missed work—the days don't have to be consecutive and should include partial days. Once you've finished filling out all the information for the form, double-check your answers and make sure you followed all the instructions. Be sure to sign and date the form. If you're unable to sign the form yourself, an attorney, representative, or dependant may sign the form on your behalf. Don't forget to make a copy of the completed form before you mail it to the North Carolina Industrial Commission. If you have any questions about filling out a Form Eighteen or filing a workers' compensation claim, HensonFuerst is here to help.