Link to law: http://reports.oah.state.nc.us/ncac/title 04 - commerce/chapter 10 - industrial commission/subchapter l/04 ncac 10l .0101.html
Published: 2015

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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.