Free Form 24 - North Carolina


File Size: 32.8 kB
Pages: 2
File Format: PDF
State: North Carolina
Category: Workers Compensation
Author: Mcdowelr
Word Count: 646 Words, 4,017 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ic.nc.gov/ncic/pages/form24.pdf

Download Form 24 ( 32.8 kB)


Preview Form 24
North Carolina Industrial Commission
IC File #

APPLICATION TO TERMINATE OR SUSPEND PAYMENT OF COMPENSATION (G.S. 97-18.1)
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address

Emp. Code # Carrier Code # Carrier File # Employer FEIN

(

)
Telephone Number City State Zip

(

) M F

( /

)
City State Fax Number Zip

Home Telephone Social Security Number Sex

Work Telephone

/

(

)

(

)

Date of Birth

Carrier's Telephone Number

IMPORTANT NOTICE TO EMPLOYEE: YOUR BENEFITS MAY BE STOPPED UNLESS YOU OBJECT IMMEDIATELY. IF YOU BELIEVE YOUR
BENEFITS SHOULD NOT BE STOPPED, YOU MUST FILL OUT SECTION B. OF THIS FORM AND RETURN ONE COPY OF THIS FORM TO THE INDUSTRIAL COMMISSION. IF THE INDUSTRIAL COMMISSION HAS NOT RECEIVED THE COMPLETED COPY OF THIS FORM FROM YOU BY YOUR BENEFITS MAY BE STOPPED WITHOUT FURTHER NOTICE TO YOU. IF YOU OBJECT, YOU MAY HAVE THE RIGHT TO AN INFORMAL HEARING BY THE INDUSTRIAL COMMISSION BEFORE YOUR BENEFITS CAN BE STOPPED. (THE DATE TO BE INSERTED ABOVE BY THE EMPLOYER OR CARRIER/ADMINISTRATOR SHALL BE 17 DAYS AFTER THIS APPLICATION WAS MAILED TO THE INDUSTRIAL COMMISSION.)

,

SECTION A.

TO BE COMPLETED BY THE EMPLOYER OR CARRIER/ADMINISTRATOR:
Date disability began :

1. Date of injury by accident : 2. Nature and extent of injury:

3. Number of weeks compensation paid: 4. Total amount of indemnity compensation paid to date: $

From :

To :

5. Check applicable box(s): a. An agreement was approved by the Industrial Commission on b. The employer admitted employee's right to compensation pursuant to N.C. Gen. Stat. § 97-18(b). c. The employer paid compensation to employee without contesting claim within the statutory period provided under N.C. Gen. Stat. § 97-18(d). d. Other: 6. Application is made to terminate or suspend compensation to the employee on the grounds that

7.

Check box if employee is in managed care.

FORM 24 2/01 PAGE 1 OF 2

FORM 24

MAIL TO: NCIC - EXECUTIVE SECRETARY 4333 MAIL SERVICE CENTER RALEIGH, NC 27699-4333 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/

In addition to filing the original of this application and supporting documents with the Industrial Commission, I hereby certify that a copy of this application, together with all supporting documents, was mailed to the employee at (address) and employee's attorney of record, if any, on The attached documents consist of . (number) pages.

SIGNATURE OF EMPLOYER OR CARRIER/ADMINISTRATOR

PRINTED NAME

TELEPHONE NUMBER

DATE

TO BE COMPLETED BY THE EMPLOYEE SECTION B. IF YOU THINK YOUR COMPENSATION SHOULD NOT BE STOPPED, YOU SHOULD COMPLETE THIS SECTION.
1. I do not think my compensation should be stopped because:

2. Enclose and specify the number of pages of documents the Industrial Commission should consider: (number).

3. Give a telephone number at which you can be reached when the informal hearing is scheduled, from Monday through Friday between 8:00 a.m. and 5:00 p.m.: . The Industrial Commission will notify you of the date and time of the hearing.

SIGNATURE OF EMPLOYEE

WITNESS

DATE

If you need assistance in completing this form, you may contact the Industrial Commission at (800) 688-8349. You must contact the

Office of the Executive Secretary at (919) 807-2500 to obtain an extension of time in which to submit medical records, or to obtain

documents you have not been able to obtain.

EMPLOYEE: SEND A COPY OF THIS FORM AND SUPPORTING DOCUMENTS TO THE EMPLOYER AND CARRIER/ADMINISTRATOR FROM WHOM YOU ARE RECEIVING COMPENSATION. SEND THE ORIGINAL TO: INDUSTRIAL COMMISSION, OFFICE OF THE EXECUTIVE SECRETARY, 4333 MAIL SERVICE CENTER, RALEIGH NC 27699-4333.

FORM 24 2/01 PAGE 2 OF 2

FORM 24

MAIL TO: NCIC - EXECUTIVE SECRETARY 4333 MAIL SERVICE CENTER RALEIGH, NC 27699-4333 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/