Fillable FORM 17 Revised 10/2017: N.C. WORKERS COMPENSATION NOTICE (American Lumper Services)

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FORM 17 Revised 10/2017: N.C. WORKERS COMPENSATION NOTICE (American Lumper Services)

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FORM 17 Revised 10/2017
N.C. WORKERS’ COMPENSATION NOTICE TO INJURED WORKERS AND EMPLOYERS
All employees of this business, except specifically excluded executive officers, suffering work-related
injuries may be entitled to Workers’ Compensation benefits from the employer or its insurance carrier.
IF YOU HAVE A WORK-RELATED INJURY OR AN OCCUPATIONAL DISEASE
The Employee Should:
Report the injury or occupational disease to the Employer immediately.
Give written notice to the Employer within 30 days.
File a claim with the Industrial Commission on a Form 18 immediately, but no later than 2 years from injury date or occupational disease.
Give a copy to the Employer.
If medical treatment and wage loss compensation are not promptly provided, call the insurance carrier/administrator or request a hearing
before the Industrial Commission using a Form 33 Request for Hearing. Commission forms are available at website www.ic.nc.gov or by
calling the Help Line.
Your employer’s workers’ compensation insurance carrier is ___________________________________________________________________.
The insurance policy number is ___________________________________________________________________________________________.
Your employer’s workers’ compensation insurance policy is valid from __________________________ until ___________________________.
For assistance: Call the Industrial Commission HELP LINE—(800) 688-8349.
The Employer Should:
Provide all necessary medical services to the Employee.
Report the injury to the carrier/administrator and file a Form 19 Report of Injury within 5 days with the Industrial Commission, if the
Employee misses more than 1 day from work or if cumulative medical costs exceed $2,000.00.
Give a copy of your completed Form 19 to the Employee along with a copy of a blank Form 18 Notice of Accident.
Ensure that compensation is promptly paid as required under the Workers’ Compensation Act.
For assistance with Safety Education Training contact:
Director of Safety Education at (919) 807-2602 or safety@ic.nc.gov
NORTH CAROLINA INDUSTRIAL COMMISSION
1235 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1235
Website: www.ic.nc.gov
TO EMPLOYER: THIS FORM MUST BE PROMINENTLY POSTED IF YOU HAVE WORKERS’ COMPENSATION INSURANCE OR QUALIFY AS SELF-INSURED. (N.C. Gen. Stat. §97-93).
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FORM 17 Revised 102017: N.C. WORKERS COMPENSATION NOTICE (American Lumper Services)

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Completed 29 July 2021

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