Form 23 - Application To Reinstate Payment Emp. Fein # Of Disability Compensation

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North Carolina Industrial Commission
IC File #
APPLICATION TO REINSTATE PAYMENT
Emp. FEIN #
OF DISABILITY COMPENSATION (G.S. § 97-18(k))
Carrier FEIN #
Carrier File #
(
)
Employee’s 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
I
N
E
: The employee in this claim has applied for reinstatement of compensation. If the employer
MPORTANT
OTICE TO
MPLOYER
or carrier believes that compensation should not be reinstated, the employer or carrier must respond to this Application by
completing Section B of this Form and returning one copy to the Industrial Commission. If the Industrial Commission has
not received the completed copy of this Form from the employer or carrier by ____________________, an Order may be
issued reinstating compensation. If the employer or carrier timely objects to reinstatement, the matter will be scheduled for
informal telephonic hearing. (The date to be inserted above by the employee shall be 17 days after this Application was
sent to the employer or carrier and Industrial Commission, whether by mail, facsimile, or e-mail.)
S
A.
T
B
C
B
T
E
:
ECTION
O
E
OMPLETED
Y
HE
MPLOYEE
1. Date of injury by accident or occupational disease: _______________________________________________________________
2. Nature and extent of injury or occupational disease: ______________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
3. (a) Has your claim been accepted or determined to be compensable by the Industrial Commission: Yes:
No:
(b) If so, how: Form 21
Form 60
Form 63
Opinion and Award
Other________________________________________________
4. Number of weeks compensation already paid: _________ From:_______/________/_______ To:________/________/________
5. Date from which seeking compensation:________________________________________________________________________
6. Application is made to reinstate compensation on the grounds that:___________________________________________________
Y
.
OU MUST ATTACH DOCUMENTATION TO SUPPORT THIS APPLICATION FOR REINSTATEMENT OF COMPENSATION
N
P
A
: ________________
UMBER OF
AGES
TTACHED
G
,
M
F
IVE A TELEPHONE NUMBER AT WHICH YOU CAN BE REACHED IF AN INFORMAL HEARING IS SCHEDULED
FROM
ONDAY THROUGH
RIDAY BETWEEN
8:00
.
.
5:00
.
.:
______________________.
T
I
C
.
A
M
AND
P
M
HE
NDUSTRIAL
OMMISSION WILL NOTIFY YOU IF AN INFORMAL HEARING IS SCHEDULED
I
I
C
, I
N ADDITION TO FILING THE ORIGINAL OF THIS APPLICATION AND SUPPORTING DOCUMENTS WITH THE
NDUSTRIAL
OMMISSION
HEREBY CERTIFY
,
,
/
:
THAT A COPY OF THIS APPLICATION
TOGETHER WITH ALL SUPPORTING DOCUMENTS
WAS SENT TO THE EMPLOYER OR CARRIER
ADMINISTRATOR AT
(
/F
N
):____________________________________________________________________________________________
ADDRESS
AX
O
S
E
A
:____________________________________________________D
:___________________
IGNATURE OF
MPLOYEE OR
TTORNEY
ATE
A
/C
:
TTORNEYS
ARRIERS
F
E
D
F
P
ILE VIA
LECTRONIC
OCUMENT
ILING
ORTAL
://
.
.
.
/
.
HTTP
WWW
IC
NC
GOV
DOCFILING
HTML
E
F
O
:
MPLOYEE
ILING
PTIONS
F
23
ORM
E-
@
.
.
MAIL TO EXECSEC
IC
NC
GOV
F
23
ORM
02/2016
F
(919) 715-0282
AX TO
1
P
2
M
NCIC-E
S
AIL TO
XECUTIVE
ECRETARY
AGE
OF
4333 M
S
C
AIL
ERVICE
ENTER
R
, NC 27699-4333
ALEIGH
H
: (800) 688-8349
ELPLINE
W
:
://
.
.
.
EBSITE
HTTP
WWW
IC
NC
GOV

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