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Form 22 2017-2026

Use a Form 22 2017 template to make your document workflow more streamlined.

Birth 7 8 Insurance Carrier - Work Telephone XXX-XX- Year: 20 State , City ( , City , , Carrier's Address ( ) - ( Carrier's Telephone Number ) Zip Fax Number 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Amount Earned Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. Total Was this employee given free rent, lodging, or board or other allowances made in lieu of wages? If so, state weekly value thereof: $ FORM 22 02/2017 PAGE 1 OF...

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What is the Form 22

The Form 22 is a critical document used in the context of workers' compensation in North Carolina. Specifically, it serves as a report of the employee's average weekly wage, which is essential for determining the benefits an injured worker may receive. This form is typically filed with the North Carolina Industrial Commission and plays a vital role in the claims process for workers' compensation benefits.

How to use the Form 22

Using the Form 22 involves several key steps. First, ensure that you have the correct version of the form, which can be obtained from the North Carolina Industrial Commission's website. Next, accurately fill in the required information, including the employee's wages, hours worked, and any additional relevant details. Once completed, submit the form as part of the workers' compensation claim process, ensuring all necessary documentation accompanies it.

Steps to complete the Form 22

Completing the Form 22 requires attention to detail. Begin by gathering all necessary information about the employee's earnings and work schedule. Follow these steps:

  • Enter the employee's name, Social Security number, and other identifying information.
  • Document the employee's average weekly wage, including any overtime or bonuses.
  • Provide details about the employee's job title and responsibilities.
  • Review the completed form for accuracy before submission.

Legal use of the Form 22

The Form 22 is legally binding when filled out and submitted correctly. It must comply with the regulations set forth by the North Carolina Industrial Commission. Proper use of the form ensures that the employee's wage information is accurately represented, which is crucial for the determination of benefits. Failure to provide accurate information can lead to delays or denials in claims.

Key elements of the Form 22

Several key elements must be included in the Form 22 for it to be valid. These include:

  • The employee's full name and contact information.
  • The employer's details, including the company name and address.
  • A detailed account of the employee's average weekly wage.
  • Any other relevant information that supports the claim.

Form Submission Methods

The Form 22 can be submitted through various methods. It is essential to choose the most appropriate method based on the specific circumstances of the case. Common submission methods include:

  • Online submission through the North Carolina Industrial Commission's portal.
  • Mailing a hard copy of the completed form to the appropriate office.
  • In-person delivery to the Industrial Commission office.

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