F
ORM 19
REV1.2 8/13/12
PAGE 1 OF 2
FOR IC USE ONLY
R
ESEARCHER:______
CC:_____________
EC:_____________
D
ATA ENTRY:______
F
ORM 19
SELF-INSURED EMPLOYER OR CARRIER MAIL TO:
NCIC
- CLAIMS ADMINISTRATION
4335 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-4335
M
AIN TELEPHONE: (919) 807-2500
HELPLINE: (800) 688-8349
WEBSITE: HTTP://WWW.IC.NC.GOV/
North Carolina Industrial Commission
IC File #
MPLOYER’S REPORT OF EMPLOYEE’S INJURY OR
Emp. FEIN
OCCUPATIONAL DISEASE TO THE INDUSTRIAL COMMISSION
Carrier FEIN
To the Employer:
A copy of this Form 19 accompanied by a blank Form 18 must be given to the employee. It does
not satisfy the employee’s obligation to file a claim. The filing of this report is required by law.
This form MUST be transmitted to the Industrial Commission through your Insurance Carrier.
To the Employee:
This Form 19 is not your claim for workers’ compensation benefits. To make a claim, you must complete
and sign the enclosed Form 18 and mail it to Claims Administration, N.C. Industrial Commission, 4335
Mail Service Center, Raleigh, NC 27699-4335 within two years of the date of your injury or last payment
of medical compensation. For occupational diseases, the claim must be filed within two years of the date
of disability or the date your doctor told you that you have a work-related disease, whichever is later.
The use of this form is required under the provisions of the Workers’ Compensation Act
Carrier File #
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.
( ) -
Employee’s Name
Employer’s Name Telephone Number
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 Fax Number
Employe
1.
Give nature of employer’s business
2. Location of plant where injury occurred
Time
County
Department State if employer’s premises
And
3. Date of injury
4. Day of week Hour of day :
A.M. P.M.
Place
5. Was employee paid for entire day 6. Date disability began / /
A.M. P.M.
7. Date you or the supervisor first knew of injury / / 8. Name of supervisor
9. Occupation when injured
Person
10. (a) Time employed by you
(b) Wages per hour
$
Injured
11. (a) No. hours worked per day
(b) Wages per day
$
(c) No. of days worked per week
(d) Avg. weekly wages w/ overtime
$
(e) If board, lodging, fuel or other advantages were
furnished in addition to wages, estimated value per day, week or month.
$ per
12. Describe fully how injury occurred and what employee was doing when injured:
Cause
And Nature
Of Injury
(Statement made without prejudice and without vouching for correctness of information)
13.
List all injuries and specify body part involved (e.g. right hand or left hand):
14. Date & hour returned to work / / at : .M. 15. If so, at what wages
$ per
16. At what occupation
17. Employee’s salary continued in full?
18. Was employee treated by a physician
Fatal Cases
19. Has injured employee died
20. If so, give date of death (Submit Form 29)
Employer name Date Completed / /
Signed by Official Title
OSHA 301 Information:
Case Number from Log:
Date Hired:
/ /
Time Employee began work on date of incident:
:
A.M. P.M.
If off-site medical treatment provided,
answer entire next line.
Name of facility:
Address: Street/City/Zip/Telephone
ER visit?
Yes No
Overnight stay?
Yes No
Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to
the extent possible while the information is being used for occupational safety and health purposes.
