FORM 17 Revised 11/2014
N.C. WORKERS’ COMPENSATION NOTICE TO INJURED WORKERS AND EMPLOYERS
All employees of this business, except specifically excluded executive officers, suffering work-related
injuries may be entitled to Workers’ Compensation benefits from the employer or its insurance carrier.
IF YOU HAVE A WORK-RELATED INJURY OR AN OCCUPATIONAL DISEASE
The Employee Should:
Report the injury or occupational disease to the Employer immediately.
Give written notice to the Employer w ithin 30 days.
File a claim with the Industrial Commission on a Form 18 immediately, but no later than 2 years from injury date or occupational disease.
Give a copy to the Employer.
If medical treatment and wage loss compensation are not promptly provided, call the insurance carrier/administrator or request a hearing
before the Industrial Commission using a Form 33 Request for Hearing. Commission forms are available at website www.ic.nc.gov or by
calling the Help Line.
Your employer’s workers’ compensation insurance carrier is _______ __________________ __________________________________________.
The insurance policy number is ____________________________________________________________ _______________________________.
Your employer’s workers’ compensation insurance policy is valid from ____________ _____________ _ until ___________________________.
For assistance: Call the Industrial Commission HELP LINE—(800) 688-8349.
The Employer Should:
Provide all necessary medical services to the Employee.
Report the injury to the carrier/administrator and file a Form 19 Report of Injury within 5 days with the Industrial Commission, if the
Employee misses more than 1 day from work or if cumulative medical costs exceed $2,000.00.
Give a copy of your completed Form 19 to the Employee along with a copy of a blank Form 18 Notice of Accident.
Ensure that compensation is promptly paid as required under the Workers’ Compensation Act.
For assistance with Safety Education Training contact:
NORTH CAROLINA INDUSTRIAL COMMISSION
4335 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-4335
TO EMPLOYER: THIS FORM MUST BE PROMINENTLY POSTED IF YOU HAVE WORKERS’ COMPENSATION INSURANCE OR QUALIFY AS SELF-INSURED. (N.C. Gen. Stat. §97-93).