Free Form 28B - North Carolina

North Carolina Industrial Commission

REPORT OF EMPLOYER OR CARRIER/ADMINISTRATOR OF COMPENSATION AND MEDICAL COMPENSATION PAID AND NOTICE OF RIGHT TO ADDITIONAL MEDICAL COMPENSATION
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 City City

IC File #________ Emp. Code #________ Carrier Code #________ Carrier File #________ Employer FEIN________

)
Telephone Number State Zip

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) M F

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State Fax Number Zip

Home Telephone Social Security Number Sex

Work Telephone

/

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)

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Date of Birth

Carrier's Telephone Number

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

12. 13.

. Date of accident or disability from occupational disease_____________________________. Salary was / was not continued. Total Dollar Amount Number of weeks temporary total from , through $_________________ from , through $_________________ Number of weeks temporary partial from , through $_________________ from , through $_________________ Number of weeks permanent partial from , through $_________________ Disfigurement amount paid $ Death benefits paid $ Loss of organ or body part benefits paid $ Total of lines 3 through 8, including any attorney fee paid to employee's attorney $ Compromise Settlement Agreement amount $ Does this include final medical? Yes / No a. Total medical paid $ (Include bills for nursing, doctor, hospital, drugs, etc., but exclude rehabilitation and "medical only" paid) b. Total rehabilitation paid $ c. Total "medical only" paid $ Total of lines 9, 10, 11a, and 11b. $ Miscellaneous payments: Funeral benefits $ Total Miscellaneous Payments Second injury fund $ Hearing Costs $ Expert witness fees $ $ Other $ Has employee returned to work? Yes / No If so, on what date? At what wage? Yes / Date last compensation check forwarded Was this the final payment? Yes / Date last medical compensation paid Was this the final payment?

14. 15. 16.

No No

NAME OF EMPLOYER OR CARRIER/ADMINISTRATOR

SIGNATURE TITLE DATE This form must be filed with the Industrial Commission at the address below, and a copy provided the employee with his last compensation check within 16 days following final payment of compensation and final medical payment.

MAIL TO:
FORM 28B 11/2003 PAGE 1 OF 2

FORM 28B

NCIC - STATISTICS SECTION 4334 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4334 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349

FOR INDUSTRIAL COMMISSION USE ONLY Days Medical IC Code: ____________________ $____________________ ____________________ Compensation Paid $____________________

IMPORTANT NOTICE TO EMPLOYEE CLAIMING ADDITIONAL WEEKLY COMPENSATION CHECKS OR LUMP SUM PAYMENT 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 CLAIMING ADDITIONAL MEDICAL BENEFITS INJURED BEFORE JULY 5, 1994 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 CLAIMING ADDITIONAL MEDICAL BENEFITS INJURED ON OR AFTER JULY 5, 1994 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.

DEFINITION OF MEDICAL COMPENSATION The term "medical compensation" means medical, surgical, hospital, nursing and rehabilitative services, and medicines, sick travel, and other treatment, including medical and surgical supplies, as may reasonably be required to effect a cure or give relief, and for such additional time, as in the judgment of the Industrial Commission, will tend to lessen the period of disability; and any original artificial members as may reasonably be necessary at the end of the healing period, and the replacement of such artificial members when reasonably necessitated by ordinary use or medical circumstances. N.C. Gen. Stat. § 97-2(19).

NEED ASSISTANCE? If you have questions or need help and you do not have an attorney, you may contact the Industrial Commission' Ombudsman at (800) 688-8349

MAIL TO:
FORM 28B 11/2003 PAGE 2 OF 2

FORM 28B

NCIC - STATISTICS SECTION 4334 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4334 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349