SUBCHAPTER 10L – INDUSTRIAL COMMISSION FORMS
SECTION .0100 – WORKERS’ COMPENSATION FORMS
04 NCAC 10L .0101 FORM 21 – AGREEMENT FOR COMPENSATION
FOR DISABILITY
(a) (Effective until July 1, 2015) The parties to a
workers' compensation claim shall use the following Form 21, Agreement for
Compensation for Disability, for agreements regarding disability and
payment of compensation therefor pursuant to G.S. 97-29 and 97-30. Additional
issues agreed upon by the parties such as payment of compensation for permanent
partial disability may also be included on the form. This form is necessary to
comply with Rule 04 NCAC 10A .0501, where applicable. The Form 21, Agreement
for Compensation for Disability, shall read as follows:
North Carolina Industrial
Commission
Agreement for
Compensation for Disability
(G.S. 97-82)
IC File # __________
Emp. Code # __________
Carrier Code # __________
Carrier File # __________
Employer FEIN __________
The Use Of This Form Is
Required Under The Provisions of The Workers' Compensation Act
____________________________________________________________
Employee's Name
____________________________________________________________
Address
____________________________________________________________
City
State Zip
____________________________________________________________
Home
Telephone Work
Telephone
Social Security Number:
_______ Sex: M F Date of Birth:
_______
____________________________________________________________
Employer's
Name Telephone Number
____________________________________________________________
Employer's
Address City State Zip
____________________________________________________________
Insurance Carrier
____________________________________________________________
Carrier's Address
City State Zip
____________________________________________________________
Carrier's Telephone
Number Carrier's Fax Number
We, The Undersigned, Do
Hereby Agree And Stipulate
As Follows:
1. All
parties hereto are subject to and bound by the provisions of the Workers'
Compensation Act and __________ is the carrier/administrator
for the employer.
2. The
employee sustained an injury by accident or the employee contracted an
occupational disease arising out of and in the course of employment on or by
__________ .
3. The injury
by accident or occupational disease resulted in the following injuries:
__________
________________________________________________________________________________.
4. The
employee
was/ was not paid
for the entire day when the injury occurred.
5. The
average weekly wage of the employee at the time of the injury, including
overtime and all allowances, was $________, subject
to verification unless otherwise agreed upon in Item 9 below.
6. Disability
resulting from the injury or occupational disease began on ________.
7. The
employer and carrier/administrator
hereby undertake to pay compensation to the employee at the rate of $________
per week beginning ________, and continuing for ________ weeks.
8. The
employee has /
has not returned to work
for ________________________________
on ________________ , at
an average weekly wage of $________.
9. State any
further matters agreed upon, including disfigurement, permanent partial, or
temporary partial disability:
________________________________________________________________.
10. If
applicable, the Second Injury Fund Assessment is $________.
Check
is is not attached.
11. The date of
this agreement is ________. Date of first payment: ________ Amount: ________.
12. IMPORTANT
NOTICE TO EMPLOYEE: The Industrial Commission’s fee for processing this
agreement is $300.00 to be paid in equal shares by the employee and the employer.
You are not required to pay your portion of the fee in advance, and if your
award is $3,000.00 or less, you are not responsible for any portion of the fee.
If your award is more than $3,000.00, the employer shall deduct $150.00 from
your award, unless you and your employer agree otherwise.
Check one of the boxes
below if the award is more than $3,000.00:
The employer will deduct $150.00 from the
amount to be paid pursuant to this agreement.
The employee and employer have agreed that
the employer will pay the entire fee.
__________________________________________________________________________________
Name Of
Employer
Signature Title
__________________________________________________________________________________
Name Of Carrier /
Administrator
Signature Title
By signing I enter into
this agreement and certify that I have read the “Important Notices to Employee”
printed on Pages 1 and 2 of this form.
__________________________________________________________________________________
Signature of Employee Address
__________________________________________________________________________________
Signature of Employee's
Attorney Address
North Carolina Industrial Commission
The Foregoing Agreement
Is Hereby Approved:
___________________________________________
Claims
Examiner Date
___________________________________________
Attorney's Fee Approved
Check Box If No Attorney Retained.
Check Box If Employee Is In Managed Care.
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, Employee’s
Application for Additional Medical Compensation (G.S. 97-25.1), available
at http://www.ic.nc.gov/forms.html.
IMPORTANT NOTICE TO
EMPLOYER
The employee must be
provided a copy when the agreement is signed by the employee. Pursuant to Rule
04 NCAC 10A .0501, 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 cause for not submitting the agreement. The
employer or carrier/administrator shall file a Form 28B, Report of Compensation
and Medical Compensation Paid, within 16 days after the last payment made
pursuant to this agreement or be subject to a penalty.
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 21
11/2014
Self-Insured Employer or
Carrier, Mail to:
NCIC - Claims Section
4335 Mail Service Center
Raleigh, NC 27699-4335
Telephone: (919) 807-2502
Helpline: (800) 688-8349
Website:
http://www.ic.nc.gov/
(a) (Effective July
1, 2015) The parties to a workers' compensation claim shall use the
following Form 21, Agreement for Compensation for Disability, for
agreements regarding disability and payment of compensation therefor pursuant
to G.S. 97-29 and 97-30. Additional issues agreed upon by the parties such as
payment of compensation for permanent partial disability may also be included
on the form. This form is necessary to comply with Rule 04 NCAC 10A .0501,
where applicable. The Form 21, Agreement for Compensation for Disability,
shall read as follows:
North Carolina Industrial
Commission
Agreement for
Compensation for Disability
(G.S. 97-82)
IC File # __________
Emp. Code # __________
Carrier Code # __________
Carrier File # __________
Employer FEIN __________
The Use Of This Form Is
Required Under The Provisions of The Workers' Compensation Act
____________________________________________________________
Employee's Name
____________________________________________________________
Address
____________________________________________________________
City
State Zip
____________________________________________________________
Home
Telephone Work
Telephone
Social Security Number:
_______ Sex: M F Date of Birth:
_______
____________________________________________________________
Employer's
Name Telephone Number
____________________________________________________________
Employer's
Address City State Zip
____________________________________________________________
Insurance Carrier
____________________________________________________________
Carrier's
Address City State
Zip
____________________________________________________________
Carrier's Telephone
Number Carrier's Fax Number
We, The Undersigned, Do
Hereby Agree And Stipulate As Follows:
1. All
parties hereto are subject to and bound by the provisions of the Workers'
Compensation Act and __________ is the carrier/administrator for the employer.
2. The
employee sustained an injury by accident or the employee contracted an
occupational disease arising out of and in the course of employment on or by
__________.
3. The injury
by accident or occupational disease resulted in the following injuries:
__________
________________________________________________________________________________.
4. The
employee was/ was not paid for the
entire day when the injury occurred.
5. The
average weekly wage of the employee at the time of the injury, including
overtime and all allowances, was $________, subject to verification unless
otherwise agreed upon in Item 9 below.
6. Disability
resulting from the injury or occupational disease began on ________.
7. The
employer and carrier/administrator hereby undertake to pay compensation to the
employee at the rate of $________ per week beginning ________, and continuing
for ________ weeks.
8. The
employee has / has not returned to work
for ________________________________
on ________________ , at
an average weekly wage of $________.
9. State any further
matters agreed upon, including disfigurement, permanent partial, or temporary
partial disability:
________________________________________________________________.
10. If
applicable, the Second Injury Fund Assessment is $________. Check is is not attached.
11. The date of
this agreement is ________. Date of first payment: ________ Amount: ________.
__________________________________________________________________________________
Name Of
Employer Signature
Title
__________________________________________________________________________________
Name Of Carrier /
Administrator
Signature Title
By signing I enter into
this agreement and certify that I have read the “Important Notices to Employee”
printed on Page 2 of this form.
__________________________________________________________________________________
Signature of Employee Address
__________________________________________________________________________________
Signature of Employee's
Attorney Address
North Carolina Industrial
Commission
The Foregoing Agreement
Is Hereby Approved:
___________________________________________
Claims Examiner Date
___________________________________________
Attorney's Fee Approved
Check Box If No Attorney Retained.
Check Box If Employee Is In Managed Care.
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, Employee’s Application
for Additional Medical Compensation (G.S. 97-25.1), available at
http://www.ic.nc.gov/forms.html.
IMPORTANT NOTICE TO
EMPLOYER
The employee must be
provided a copy when the agreement is signed by the employee. Pursuant to Rule
04 NCAC 10A .0501, 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 cause for not submitting the agreement.
The employer or carrier/administrator shall file a Form 28B, Report of
Compensation and Medical Compensation Paid, within 16 days after the last
payment made pursuant to this agreement or be subject to a penalty.
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 21
7/2015
Self-Insured Employer or
Carrier, Mail to:
NCIC - Claims Section
4335 Mail Service Center
Raleigh, NC 27699-4335
Telephone: (919) 807-2502
Helpline: (800) 688-8349
Website: http://www.ic.nc.gov/
(b) The copy of the form
described in Paragraph (a) of this Rule can be accessed at http://www.ic.nc.gov/forms/form21.pdf. The form may be reproduced
only in the format available at http://www.ic.nc.gov/forms/form21.pdf and may not be altered or
amended in any way.
History Note: Authority G.S. 97-73; 97-80(a); 97-81(a);
97-82; S.L. 2014-77;
Eff. November 1, 2014.