Fillable Form 28603: NOTICE OF ACCIDENT TO EMPLOYER AND (City of Hickory)

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Form 28603: NOTICE OF ACCIDENT TO EMPLOYER AND (City of Hickory)

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FORM 18
03/2018
P
AGE 1 OF 1
FOR IC USE ONLY
R
ESEARCHER: ______
CC:
_____________
EC:
_____________
D
ATA ENTRY: ______
FORM 18
ATTORNEYS: FILE WITH AN IC FILE NUMBER VIA EDFP
HTTP
://WWW.IC.NC.GOV/DOCFILING.HTML OR
I
F NO IC FILE NUMBER, FOLLOW EMPLOYEE FILING OPTIONS.
E
MPLOYEES: E-MAIL TO: FORMS@IC.NC.GOV
OR MAIL TO: NCIC - CLAIMS SECTION
1235
MAIL SERVICE CENTER
R
ALEIGH, NC 27699-1235
M
AIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349
W
EBSITE: HTTP://WWW.IC.NC.GOV
/
The I.C. File # is the unique identifier for
this injury. It will be provided by return
letter and is to be referenced in all future
correspondence.
North Carolina Industrial Commission
NOTICE OF ACCIDENT TO EMPLOYER AND CLAIM OF
EMPLOYEE, REPRESENTATIVE, OR DEPENDENT
(G.S. §§97-22 THROUGH 24)
The Us
e of This Form Is Required Under the Provisions of the Workers' Compensation Act
Employee’s Name Employer's Name Telephone Number
A
ddress Employer’s Address City State Zip
City State Zip Insurance Carrier Policy Number
Home Telephone Work Telephone Carrier’s Address City State Zip
M F
(
Social Security Number Sex Date of Birth Carrier’s Telephone Number Carrier’s Fax Number
EMPLOYEE – This form must be filed with the Industrial Commission within two years of the date of injury o
r
occupational disease or your claim may be barred. Notice shall be given to the employer immediately after the
accident or as soon as practicable and within 30 days. (This form should also be used for occupational disease
claims; however, for asbestosis, silicosis and b
y
ssinosis, Form 18B is to be used.
)
Notice is hereb
y
g
iven, as required b
y
law, that the above-named emplo
y
ee sustained an in
j
ur
y
or contracted an occupational disease,
described as follows: on at
.
Describe the injury or occupational disease,
Time of Injury Date (required) City and County
includin
g
the specific bod
y
part involved
e.
., ri
ht hand, left hand
Describe how the injury or occupational disease occurred:
Nature of employer’s business:
Occupation when injured:
Number of da
ys out of work due to injury:
Medical treatment received? Yes
Weekly wage:
No
Number of hours worked per day:
Da
y
s worked per week:
NOTE: If employee is unable to sign this form, another may sign for him. This form should be typed or printed by hand in
black ink, if possible. Employee should retain one signed copy of this notice, mail one signed copy to the Industrial
Commission at the address below, and provide one si
g
ned cop
y
to emplo
y
er.
Signature of (Check One) Employee, Attorney,
Representative, or Dependent
Printed Name of Signer E-mail Address Telephone Number
Address
City
State Zip Code
Date Completed
EMPLOYER: This notice is being sent to you in compliance with requirements of the North Carolina Workers’
Compensation Act, in order that the medical services prescribed by the Act may be obtained; and, if disability extends
be
y
ond 7 da
y
s duration, or if death ensues, compensation ma
y
be paid accordin
g
to law.
City of Hickory
(828)323-7421
PO Box 398 Hickory
NC
28603
Compensation Claims Solutions
Self Insured
1287 Old Charlotte Road
Concord
NC
28027
)
800 883 - 2853
- (704) 786 - 9821
IC File #
Employee Code
Carrier Code
Employer FEIN
Carrier File #
92900070
999112
56-6001244
Reset
GENERAL INFORMATION ON THE FORM 18
1. What does a Form 18 do?
A Form 18 establishes a legal claim of injury on your behalf if filed within two years of the date of injury or occupational
disease, and gives the required written notice to the employer if a copy is submitted to the employer within 30 days of the
injury. The employer is required by law to file a Form 19 if the employee misses more than one day of work due to the
injury or if the medical bills exceed $2,000.00. However, the employer’s filing of a Form 19 does not satisfy the
employee’s obligation to file a claim. In order to ensure the employee’s rights are protected, the employee must file a
Form 18 even though the employer may be paying compensation or the Industrial Commission may have opened a file for
the injury.
2. To whom should the Form 18 be sent?
The original Form 18 should be submitted to the Industrial Commission. The injured worker should keep one copy for his
or her records and one copy should be submitted to the employer at the time of the injury.
3.
What numbers do I writ
e in the upper right corner?
You do not
need to fill in the spaces on the upper right corner of the Form 18. If you know that your employer has already
filed a report of injury, (Form 19) and you know what your I.C. (Industrial Commission), File Number is, you may write
the number in the “I.C. File No.” space. If you do not already have an I.C. File Number, the Industrial Commission will
assign one upon receipt of the Form 18. The other three spaces, “Emp. Code No.,” “Carrier Code No.,” and “Employer
FEIN” are for internal use only.
4. What if I do not know who my employer’s insurance carrier is?
If you do not know who the employer’s insurance carrier is you may either ask your employer for the information, call the
Industrial Commission’s Claims Administration Section at (800) 688-8349 then press “1” after the prompt, or simply
leave the line blank.
5.
When listing the number of days out
of work, do I count partial days?
Yes, you include partial as well as whole calendar days not worked. However, the days do not need to be consecutive.
6. What happens after I file the Form 18?
The Industrial Commission will mail an acknowledgement letter to you after your Form 18 is processed. Processing time
varies according to current workload. The Industrial Commission will mail a copy of the acknowledgement letter to the
employer or its workers’ compensation insurance carrier asking them to contact you and inform you if compensation will
be paid to you voluntarily.
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Form 28603: NOTICE OF ACCIDENT TO EMPLOYER AND (City of Hickory)

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Completed 23 January 2021

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