Ncic Form 28b

MAIL TO FORM 28B 11/2003 PAGE 1 OF 2 NCIC - STATISTICS SECTION 4334 MAIL SERVICE CENTER RALEIGH NORTH CAROLINA 27699-4334 MAIN TELEPHONE 919 807-2500 HELPLINE 800 688-8349 FOR INDUSTRIAL COMMISSION USE ONLY Days Compensation Paid Medical IC Code IMPORTANT NOTICE TO EMPLOYEE CLAIMING ADDITIONAL WEEKLY COMPENSATION CHECKS OR LUMP SUM PAYMENT If you claim further compensation you must notify the Industrial Commission in writing within two years from the date of receipt of your last compensation check or your rights to these benefits may be lost. North Carolina Industrial Commission IC File REPORT OF EMPLOYER OR CARRIER/ADMINISTRATOR OF COMPENSATION AND MEDICAL COMPENSATION PAID AND NOTICE OF RIGHT TO ADDITIONAL MEDICAL COMPENSATION Emp* Code Carrier Code Carrier File Employer FEIN The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act Employee s Name Address Employer s Address City State Home Telephone Sex Zip Insurance Carrier Work Telephone M Social Security Number Telephone Number F / Date of Birth Carrier s Address Carrier s Telephone Number Fax Number. Date of accident or disability from occupational disease. Salary was / was not continued* Total Dollar Amount Number of weeks temporary total from through Disfigurement amount paid Death benefits paid Loss of organ or body part benefits paid Total of lines 3 through 8 including any attorney fee paid to employee s attorney Compromise Settlement Agreement amount Does this include final medical Yes / No a* Total medical paid Include bills for nursing doctor hospital drugs etc* but exclude rehabilitation and medical only paid b. Total rehabilitation paid Total of lines 9 10 11a and 11b. Miscellaneous payments Funeral benefits Total Miscellaneous Payments Second injury fund Hearing Costs Expert witness fees Other Has employee returned to work Yes / No If so on what date At what wage Yes / Date last compensation check forwarded Was this the final payment Date last medical compensation paid No NAME OF EMPLOYER OR CARRIER/ADMINISTRATOR SIGNATURE TITLE DATE This form must be filed with the Industrial Commission at the address below and a copy provided the employee with his last compensation check within 16 days following final payment of compensation and final medical payment. CLAIMING ADDITIONAL MEDICAL BENEFITS INJURED BEFORE JULY 5 1994 If your injury occurred before July 5 1994 you are entitled to medical compensation as long as it is reasonably necessary related to your workers compensation case and authorized by the carrier or the Industrial Commission* INJURED ON OR AFTER JULY 5 1994 payment of future medical compensation will terminate two years after your employer or carrier/administrator last pays any medical compensation or other compensation whichever occurs last. If you think you will need future medical compensation you must apply to the Industrial Commission in writing within two years or your right to these benefits may be lost. To apply you may also use Industrial Commission Form 18M. DEFINITION OF MEDICAL COMPENSATION The term medical compensation means medical surgical hospital nursing and rehabilitative services and medicines sick travel and other treatment including medical and surgical supplies as may reasonably be required to effect a cure or give relief and for such additional time as in the judgment of the Industrial Commission will tend to lessen the period of disability and any original artificial members as may reasonably be necessary at the end of the healing period and the replacement of such artificial members when reasonably necessitated by ordinary use or medical circumstances.