Industrial Commission Forms and Office Locations – Government Agency in North Carolina

1 - 20 of 73 forms

Form Title	Topics
APPLICATION FOR APPOINTMENT OF GUARDIAN Emp. Code # AD LITEM
APPLICATION FOR LUMP SUM AWARD
APPLICATION TO TERMINATE OR SUSPEND PAYMENT OF COMPENSATION (G.S. § 97-18.1)
AUTHORIZATION FOR REHABILITATION PROFESSIONAL TO OBTAIN MEDICAL RECORDS OF CURRENT TREATMENT
Certification of Payment of Compromise Settlement Agreement Fee
Certification of Payment of Processing Fee for the Form 33I
Claim for Compensation under the Eugenics Asexualization and Sterilization Compensation Program
CSA Processing Fee
EMPLOYEE’S APPLICATION FOR ADDITIONAL MEDICAL COMPENSATION (G.S. § 97-25.1)
EMPLOYEE'S REQUEST THAT COMPENSATION BE REINSTATED AFTER UNSUCCESSFUL TRIAL RETURN
EMPLOYER’S REPORT OF EMPLOYEE’S INJURY OR OCCUPATIONAL DISEASE TO THE INDUSTRIAL COMMISSION
Form 25PR, Request for Preauthorization of Medical Treatment
Form 25R, Evaluation for Permanent Impairment
Form 25T, Itemized Statement of Travel Charges
Form 26A, Employer's Admission of Employee's Right to Permanent Partial Disability
Form 26D, Agreement for Payment of Unpaid Compensation in Unrelated Death Cases
Form 26I, Medical Provider Dispute Resolution Questionnaire
Form 26, Supplemental Agreement as to Payment of Compensation
Form 28B, Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation
Form 28C, Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid Pursuant to a Compromise Settlement Agreement

Industrial Commission