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Free Form 26A - North Carolina



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Excerpt: North Carolina Industrial Commission EMPLOYER'S ADMISSION OF EMPLOYEE'S RIGHT TO PERMANENT PARTIAL DISABILITY (G.S. 97-31) The Use of This Form Is Required Under the Provisions of The Workers' Compensation Act _____________________________________________ Employee's Name _____________________________________________ Address ___________________________
North Carolina Industrial Commission

EMPLOYER'S ADMISSION OF EMPLOYEE'S RIGHT TO PERMANENT PARTIAL DISABILITY (G.S. 97-31)
The Use of This Form Is Required Under the Provisions of The Workers' Compensation Act
_____________________________________________ Employee's Name _____________________________________________ Address _____________________________________________ City State Zip (___)___________________ Home Phone _______________ Social Security Number _(___)_______________ Work Phone _ /___/____ Date of Birth

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

_____________________________________________________ Employer's Name Phone ______________________________________________________ Employer's Address City State Zip ______________________________________________________ Insurance Carrier ______________________________________________________ Carrier's Address City State Zip (____)____________Ext.____ Carrier's Telephone Number (_____)___________________ Carrier's Fax Number

__ M_ F_

WE, THE UNDERSIGNED, DO HEREBY AGREE AND STIPULATE AS FOLLOWS: 1. 2. 3. 4. 5. 6. 7. 8. All the parties hereto are subject to and bound by the provisions of the Workers' Compensation Act and ______________________ is the Carrier/Administrator for the Employer. The employee sustained an injury by accident or the employee contracted an occupational disease arising out of and in the course of employment on _____________________. The injury by accident or occupational disease resulted in the following injuries: ______________________________________________________________________________. The employee was was not paid for the 7 day waiting period. If not, was salary continued? yes no. Was employee paid for the date of injury? yes no The average weekly wage of the employee at the time of the injury, including overtime and all allowances, was $_____________. This results in a weekly compensation rate of $____________. The employee has has not returned full time to work for _______________________________________ on ________________________, at an average weekly wage of $__________________. Claimant was released with permanent restrictions without permanent restrictions. Permanent partial disability compensation will be paid to the injured worker as follows: ____ weeks of compensation at rate of $________ per week for ____% rating to ___________ (body part) ____ weeks of compensation at rate of $________ per week for ____% rating to ___________ (body part) ____ weeks of compensation at rate of $________ per week for ____% rating to ___________ (body part) Total amount of permanent partial disability compensation is $___________. Date of first payment:______________. 9. State any further matters agreed upon, including disfigurement, loss of teeth, election of temporary partial disability, waiting period or other: _________________________________________________________________________________________. 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/

Form 26A 8/1/08 Page 1 of 3

Form 26A

10. An overpayment is claimed in the amount of $_______________. Overpayment was calculated as follows:_______________________________________________________________________. If overpayment claimed, a Form 28B is attached. yes no 11. If applicable, the Second Injury Fund Assessment is $ ___________________. A check is is not included. The undersigned hereby certify that the material medical and vocational reports related to the injury have been provided to the employee or his attorney and have been filed with the Industrial Commission for consideration pursuant to G.S. 97-82(a) and Industrial Commission Rule 501(3). _________________________________________________________________________________________ Name of Employer Signature Title Date _________________________________________________________________________________________ Name of Carrier/ Administrator Signature Direct phone number Title Date

By signing I enter into this agreement and certify that I have read the "Important Notices to Employee" printed on page 3 of this form. _________________________________________________________________________________________ Date Signature of Employee Address __________________________________________________________________________________________ Signature of Employee's Attorney Address Date

Check box if no attorney retained.

North Carolina Industrial Commission The FOREGOING AGREEMENT IS HEREBY APPROVED: ___________________________________________ NCIC Claims Examiner/ Special Deputy/ Other $____________________________ ATTORNEY FEE APPROVED

Form 26A 8/1/08 Page 2 of 3

Form 26A

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/

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.

IMPORTANT NOTICE TO EMPLOYER
The employee must be provided a copy when the agreement is signed by the employee. Failure to file Form 28B, Report Of Compensation And Medical Compensation Paid, within 16 days after last payment pursuant to this agreement may subject the employer or carrier/administrator to a penalty. Pursuant to Rule 501, 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 good cause for not submitting the agreement.

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 26A 8/1/08 Page 3 of 3

Form 26A

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/

File Size: 78.4 kB
Pages: 3
File Format: PDF
State: North Carolina
Category: Workers Compensation
Author: Mcdowelr
Word Count: 935 Words, 7,418 Characters
Page Size: Letter (8 1/2" x 11")
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