Form 33 - North Carolina Industrial Commission, Request That Claim Be Assigned For Hearing

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North Carolina Industrial Commission
IC File #
R
C
A
H
EQUEST THAT
LAIM BE
SSIGNED FOR
EARING
The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act.
(
)
Employee’s Name
(LAST NAME)
(FIRST NAME)
Employer's Name
Telephone Number
Address
Employer’s Address
City
State
Zip
City
State
Zip
Insurance Carrier
(
)
(
)
Home Telephone
Work Telephone
Carrier's Address
City
State
Zip
(
)
(
)
M
F
/
/
Social Security Number
Sex
Date of Birth
Carrier's Telephone Number
Fax Number
Date of injury:
Part of body:
City and county where the injury occurred:
Estimated length of hearing:
This case will be set in the county where the injury occurred unless otherwise authorized by the Commission. If the requesting party
wants the hearing to be set in a different county, name the county below and the reason for that location.
(County)
(Reason for setting)
I, ____________________________________,
Plaintiff/Attorney
Defendant/Attorney, respectfully notify you that the above named
parties have failed to reach an agreement regarding compensation, and I request a hearing.
We have been unable to agree because (State reason with specificity. If appealing an Administrative Order, provide the file date of the
Order and the name of the hearing officer who issued the order.):
Employee believes he or she is entitled to the following workers' compensation benefits (check all that apply):
Payment of compensation for days missed (give dates):
Payment of medical expenses/treatment:
Payment for permanent partial disability:
Payment for permanent and total disability:
Payment for scars:
Other:
Has claimant participated in mediation?
Yes
No
A
/C
:
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ARRIERS
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NC
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MPLOYEE FILING OPTIONS
F
33
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MAIL TO
DOCKETS
IC
NC
GOV
02/2016
F
(919) 715-0282
F
33
AX TO
ORM
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1
2
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NCIC-D
S
AIL TO
OCKET
ECTION
AGE
OF
4336 M
S
C
AIL
ERVICE
ENTER
R
, NC 27699-4336
ALEIGH
H
: (800) 688-8349
ELPLINE
W
:
://
.
.
.
EBSITE
HTTP
WWW
IC
NC
GOV

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