Form 18 - North Carolina Notice Of Accident To Employer
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1
2North Carolina Industrial Commission
IC File #
N
A
E
C
OTICE OF
CCIDENT TO
MPLOYER AND
LAIM OF
Emp. Code #
E
, R
,
D
MPLOYEE
EPRESENTATIVE
OR
EPENDENT
Carrier Code #
(G.S. §§97-22
24)
THROUGH
Employer FEIN
The I.C. File # is the unique identifier for
this injury. It will be provided by return
letter and is to be referenced in all future
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
correspondence.
(
)
-
Employee’s Name
Employer's Name
Telephone Number
Address
Employer’s Address
City
State
Zip
City
State
Zip
Insurance Carrier
Policy Number
(
)
-
(
)
-
Home Telephone
Work Telephone
Carrier’s Address
City
State
Zip
-
-
M
F
/
/
(
)
-
(
)
-
Social Security Number
Sex
Date of Birth
Carrier’s Telephone Number
Carrier’s Fax Number
EMPLOYEE – This form must be filed with the Industrial Commission within two years of the date of injury or
occupational disease or your claim may be barred. Notice shall be given to the employer immediately after the
accident or as soon as practicable and within 30 days. (This form should also be used for occupational disease
claims; however, for asbestosis, silicosis and byssinosis, Form 18B is to be used.)
Notice is hereby given, as required by law, that the above-named employee sustained an injury or contracted an occupational disease,
described as follows:
on
/
/
at
Describe the injury or occupational disease,
.
Time of Injury
Date (required)
City and County
including the specific body part involved (e.g., right hand, left hand)
Describe how the injury or occupational disease occurred:
Occupation when injured:
Nature of employer’s business:
Number of days out of work due to injury:
Medical treatment received?
Yes
No
Weekly wage: $
Number of hours worked per day:
Days worked per week:
NOTE: If employee is unable to sign this form, another may sign for him. This form should be typed or printed by hand in
black ink, if possible. Employee should retain one signed copy of this notice, mail one signed copy to the Industrial
Commission at the address below, and provide one signed copy to employer.
(
)
-
Signature of (Check One)
Employee,
Attorney,
Telephone Number
Representative, or
Dependent
/
/
Address
City
State
Zip
Date Completed
EMPLOYER: This notice is being sent to you in compliance with requirements of the North Carolina Workers’
Compensation Act, in order that the medical services prescribed by the Act may be obtained; and, if disability extends
beyond 7 days duration, or if death ensues, compensation may be paid according to law.
F
IC U
O
M
:
OR
SE
NLY
AIL TO
R
: ______
F
18
ESEARCHER
NCIC - C
A
ORM
LAIMS
DMINISTRATION
CC: _____________
8/1/08
M
S
C
4335
AIL
ERVICE
ENTER
EC: _____________
P
1
1
D
E
: ______
R
, N
C
AGE
OF
ATA
NTRY
27699-4335
ALEIGH
ORTH
AROLINA
M
T
:
(919) 807-2500
AIN
ELEPHONE
H
:
(800) 688-8349
ELPLINE
F
18
ORM
W
:
://
.
.
.
/
EBSITE
HTTP
WWW
IC
NC
GOV
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