North Carolina N.C. Workers' Compensation Notice to Injured Workers and Employers Mandatory

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.  FORM   17   Revised 12/2020  
N.C.  WORKERS’ COMPENSATION NOTICE TO INJURED WORKERS AND EMPLOYERS  
 
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 with in 30   days.  
• 
File  a  claim  with  the  Industrial  Commission  on  a  Form  18  immediately,  but  no  later  than  2  years  from  injury  date  or  occupatio nal 
disease. Give a copy to the   Employer.  
• 
If  medical  treatment  and  wage  loss  compensation  are  not  promptly  provided,  ca ll  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 Commissi on, if   the 
Employee misses more than 1 day from work  or   if cumulative medical costs exceed   $4,000.00.  
• 
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 req uired under the Workers’ Compensation   Act.  
 
NORTH CAROLINA INDUSTRIAL COMMISSION 
1235 MAIL SERVICE CENTER  
RALEIGH, NORTH CAROLINA 27699 - 1235  
Website:  www.ic.nc.gov  
 
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).