Workers' Compensation Forms
- Form 17 NC Workers' Compensation Notice to Injured Workers and Employers
- Form 17 NC Workers' Compensation Notice to Injured Workers and Employers (Spanish)
- Form 18 Notice of Accident to Employer and Claim of Employee, Representative, or Dependent
- Form 18 Notice of Accident to Employer and Claim of Employee, Representative, or Dependent (Spanish)
- Form 18B Claim by Employee, Representative, or Dependent for Benefits for Lung Disease
- Form 18M Employee's Application for Additional Medical Compensation (G.S. 97-25.1)
- Form 19 Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission
- Form 22 Statement of Days Worked and Earnings of Injured Employee
- Form 23 Application to Reinstate Payment of Disability Compensation (G.S. 97-18(k))
- Form 24 Application to Terminate or Suspend Payment of Compensation (G.S. 97-18.1)
- Form 25C Authorization for Rehabilitation Professionals to Obtain Medical Records of Current Treatment
- Form 25C Authorization for Rehabilitation Professionals to Obtain Medical Records of Current Treatment (Spanish)
- Form 25N Notice of Assignment of Rehabilitation Professional
- Form 25P Itemized Statement of Charges for Drugs
- Form 25PR Request for Preauthorization of Medical Treatment
- Form 25R Evaluation for Permanent Impairment
- Form 25T Itemized Statement of Travel Charges
- Form 26 Supplemental Agreement as to Payment of Compensation
- Form 26A Employer's Admission of Employee's Right to Permanent Partial Disability
- Form 26D Agreement for Payment of Unpaid Compensation in Unrelated Death Cases
- Form 26I Medical Provider Dispute Resolution Questionnaire
- Form 28 Return to Work Report
- Form 28B Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation
- Form 28C Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid Pursuant to Compromise Settlement Agreement
- Form 28T Notice of Termination of Compensation by Reason of Trial Return to Work
- Form 28U Employee's Request that Compensation be Reinstated After Unsuccessful Trial Return to Work
- Form 29 Supplemental Report to Form 19 for Fatal Accidents
- Form 30 Agreement for Compensation for Death
- Form 30A Notice of Award
- Form 31 Application for Lump Sum Award
- Form 33 Request that Claim be Assigned for Hearing
- Form 33I Intervenor's Request that Claim be Assigned for Hearing
- Form 33R Response to Request that Claim be Assigned for Hearing
- Form 36 Subpoena for Witness
- Form 42 Application for Appointment of Guardian Ad Litem
- Form 44 Application for Review
- Form 51 Annual Consolidated Fiscal Report of "Medical Only" or "Lost Time" Cases
- Form 51 Instructions
- Form 60 Employer's Admission of Employee's Right to Compensation
- Form 61 Denial of Workers' Compensation Claim
- Form 62 Notice of Statement of Modification of Compensation
- Form 63 Notice to Employee of Payment of Compensation Without Prejudice or Payment of Medical Compensation Without Prejudice
- Form 87A Affidavit of Accrued Arrearages
- Form 87C Certificate of Accrued Arrearages or Certified Accounting of Award
- Form 87S Statement of Accrued Arrearages
- Form 90 Report of Earnings
- Form 90 Report of Earnings (Spanish)
Mediation Forms
- Form MSC1 Consent Order for Mediated Settlement Conference
- Form MSC2 Petition for Order Referring Case to Mediated Settlement Conference
- Form MSC3 Order for Mediated Settlement Conference
- Form MSC4 Designation of Mediator
- Form MSC5 Report of Mediator
- Form MSC6 Mediator's Declaration of Interest and Qualifications
- Form MSC7 Report of Evaluator
- Form MSC8 Mediated Settlement Agreement
- Form MSC8 Mediated Settlement Agreement (Spanish)
- Form MSC9 Mediated Settlement Agreement - Alternative Form
- Form MSC9 Mediated Settlement Agreement - Alternative Form (Spanish)
Rehabilitation Forms
- Form 25C Authorization for Rehabilitation Professionals to Obtain Medical Records of Current Treatment
- Form 25C Authorization for Rehabilitation Professionals to Obtain Medical Records of Current Treatment (Spanish)
- Form 25N Notice of Assignment of Rehabilitation Professional
- Medical Rehabilitation Nurses Section Referral Form
Public Safety Employees' Death Benefits Form
Erroneous Conviction Form
Payment Certification Statements
Workers' Compensation Medical Status Questionnaire
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