ࡱ> M :bjbj== !WW rlp p p 8 d!cE"*(***,v2-L~-( D D D D D D D$F 9H0D-,",--0D9**E999-n** D9- D9\9><><*" IC`p 3><><3E0cE><H3H><9North Carolina Industrial CommissionIC File #Emp. Code # FORMTEXT      Employer s Report of Employee s Injury or Carrier Code # FORMTEXT      Occupational Disease to the Industrial Employer FEIN FORMTEXT      CommissionCarrier File # FORMTEXT      The filing of this report by an employer is required by law. It does not satisfy the employee s obligation to file a claim. This form MUST be transmitted to the Industrial Commission through Your Insurance Carrier. The use of this form is required under the provisions of the Workers Compensation Act.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.   FORMTEXT       FORMTEXT       ( FORMTEXT    )  FORMTEXT    - FORMTEXT     Employee s NameEmployer s Name Telephone Number FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      AddressEmployer s Address City State Zip FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT        FORMTEXT       City State ZipInsurance Carrier Policy Number( FORMTEXT    )  FORMTEXT    - FORMTEXT     ( FORMTEXT    )  FORMTEXT    - FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      Home TelephoneWork Telephone Carrier s Address City State Zip FORMTEXT    - FORMTEXT   - FORMTEXT       FORMCHECKBOX  M  FORMCHECKBOX  F  FORMTEXT   / FORMTEXT   / FORMTEXT   ( FORMTEXT    )  FORMTEXT    - FORMTEXT      ( FORMTEXT    )  FORMTEXT    - FORMTEXT     Social Security Number Sex Date of BirthCarrier s Telephone Number Fax NumberEmployer 1.Give nature of employer s business  FORMTEXT       2.Location of plant where injury occurred FORMTEXT      TimeCounty FORMTEXT      Department FORMTEXT      State if employer s premises FORMTEXT    And 3.Date of injury FORMTEXT   / FORMTEXT   / FORMTEXT   4.Day of week FORMTEXT      Hour of day FORMTEXT   : FORMTEXT    FORMCHECKBOX  A.M. FORMCHECKBOX  P.M.Place 5.Was employee paid for entire day FORMTEXT    6.Date disability began FORMTEXT   / FORMTEXT   / FORMTEXT    FORMCHECKBOX  A.M. FORMCHECKBOX  P.M. 7.Date you or the supervisor first knew of injury FORMTEXT   / FORMTEXT   / FORMTEXT   8.Name of supervisor FORMTEXT       9.Occupation when injured FORMTEXT      Person10.(a) Time employed by you FORMTEXT      (b) Wages per hour $ FORMTEXT      Injured11.(a) No. hours worked per day FORMTEXT   (b) Wages per day $ FORMTEXT      . FORMTEXT   (c) No. of days worked per week FORMTEXT  (d) Avg. weekly wages w/ overtime$ FORMTEXT      . FORMTEXT   (e) If board, lodging, fuel or other advantages were furnished in addition to wages, estimated value per day, week or month. $ FORMTEXT      . FORMTEXT    per  FORMTEXT      12.Describe fully how injury occurred and what employee was doing when injured  FORMTEXT      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)  FORMTEXT      14.Date & hour returned to work FORMTEXT   / FORMTEXT   / FORMTEXT    at  FORMTEXT   : FORMTEXT     FORMTEXT  .M.15.If so, at what wages$ FORMTEXT       per  FORMTEXT    FORMTEXT      16.At what occupation FORMTEXT      17.Employee s salary continued in full? FORMTEXT    18.Was employee treated by a physician FORMTEXT      Fatal Cases19.Has injured employee died FORMTEXT    20.If so, give date of death (Submit Form 29) FORMTEXT   / FORMTEXT   / FORMTEXT    Employer name  FORMTEXT      Date Completed FORMTEXT   / FORMTEXT   / FORMTEXT    Signed by Official Title FORMTEXT      OSHA 301 Information: Case Number from Log:  FORMTEXT      Date Hired:  FORMTEXT   / FORMTEXT   / FORMTEXT   Time Employee began work on date of incident:  FORMTEXT   : FORMTEXT     FORMCHECKBOX  A.M.  FORMCHECKBOX  P.M.If off-site medical treatment provided, answer entire next line.Name of facility:  FORMTEXT      Address: Street/City/Zip/Telephone  FORMTEXT      ER visit?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoOvernight stay?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoAttention: 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. Employer must furnish a copy of this form, as completed, to the employee or the employees representative when submitted to the Insurance Carrier or Claims Administrator for transmission to the Commission. Every question must be answered. This report must be transmitted to the Commission through your insurance carrier/claims administrator, and is required by law to be filed within 5 days after knowledge of accident.  IMPORTANT INFORMATION FOR EMPLOYEE Reporting an Injury If you do not agree with the description or time of the accident given on this form, you should make a written report of injury to the employer within thirty (30) days of the injury. Making A Claim To be sure you have filed a claim, complete a Form 18, Notice of Accident, within two years of the date of the injury and send a copy to the Industrial Commission and to your employer. The employer is required by law to file this Form 19, but the filing of the Form 19 does not satisfy the employees obligation to file a claim. The employee must file a Form 18 even though the employer may be paying compensation without an agreement, or the Commission may have opened a file on this claim. A claim may also be made by a letter describing the date and nature of the injury or occupational disease. This letter must be signed and sent to the Industrial Commission and to your employer. FOR ASSISTANCE OR TO OBTAIN A Form 18 from the Industrial Commission, you may call (800) 688-8349 USE YOUR I.C. FILE NUMBER (if known) OR SOCIAL SECURITY NUMBER ON ALL FUTURE CORRESPONDENCE WITH THE COMMISSION [SPANISH TRANSLATION] INFORMACIN IMPORTANTE PARA LOS EMPLEADOS Reporte de una Lesin (Reporting an Injury) Si usted no est de acuerdo con la descripcin o la hora del accidente que aparece en el formulario, debe hacer un reporte de la lesin por escrito y drselo a su empleador dentro de un perodo de treinta (30) das a partir de la fecha de la lesin. Cmo presentar una reclamacin (Making a Claim) Para ceriorarse de que ha presentado una reclamacin, complete el Formulario 18 Notificacin de Accidente dentro de un perodo de dos aos a partir de la fecha de la lesin y enve una copia a la Comisin Industrial y una copia a su empleador. Por ley, el empleador debe presentar el Formulario 19, sin embargo, el presentar el Formulario 19 no cumple con la obligacin que tiene el empleado de presentar una reclamacin. El empleado debe presentar el Formulario 18 aunque el empleador est pagando compensacin sin tener un acuerdo o si la Comisin ha creado un expediente con respecto a esta reclamacin. Tambin se puede presentar una reclamacin por medio de una carta explicando la fecha y la naturaleza de la lesin o la enfermedad ocupacional. Esta carta se debe firmar y enviar a la Comisin Industrial as como al empleador. PARA RECIBIR ASISTENCIA O PARA OBTENER EL FORMULARIO 18 DE LA COMISIN INDUSTRIAL, USTED PUEDE HABLAR AL (800) 688-8349 EN TODA LA CORRESPONDENCIA QUE ENVE A LA COMISIN INDUSTRIAL POR FAVOR ESCRIBA EL NMERO DE CASO DESIGNADO POR LA COMISIN [I.C. FILE NUMBER] (SI LO SABE) O SU NMERO DE SEGURO SOCIAL. 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