Important Forms

There are a number of forms that are used and required by the North Carolina Industrial Commission when you have a workers’ compensation claim. You can look at many of these forms on the website for the North Carolina Industrial Commission. The following is a summary of some of the forms that you may need to be familiar with. This list is not exhaustive.

Form 19: This is a Report of Your Injury form required to be filled out by your employer.
Form 18: This is the claim form the employee is required to file. This form must be filled out completely and filed with the Industrial Commission when you have been injured on the job.
Form 18B: This is a claim form for lung disease, including asbestosis, silicosis and byssinosis.
Form 33: This is a Request that Claim Be Assigned for Hearing. This hearing request form can be filed to request a hearing if you have a dispute with your employer. This form can be filed if you are not receiving all or some of the benefits to which you are entitled.
Form 25P: This is a form to List Itemized Statement for Charges or Drugs. The employee can use this form to obtain reimbursements for prescriptions.
Form 25T: This is a form to List an Itemized Statement of Charges for Travel. Employees are entitled to reimbursement for mileage if the employee travels 20 miles or more roundtrip for medical treatment.
Form 24: This is an Application to Terminate or Suspend Payment of Compensation. An employer may file this form if it is paying someone workers’ compensation benefits and seeks to terminate these benefits. If an employee is receiving compensation and disagrees that benefits should be stopped, it is very important for an employee to timely respond to the Form 24 request.

More information on other forms can be found at the NC Industrial Commission website.

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