Form 19 - Employer'S Report Of Employee'S Injury Or Occupational Disease To The Industrial Commission, Report A Claim
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1
2
3North Carolina Industrial Commission
IC File #
E
’
R
E
’
I
MPLOYER
S
EPORT OF
MPLOYEE
S
NJURY OR
Emp. FEIN
O
D
I
C
CCUPATIONAL
ISEASE TO THE
NDUSTRIAL
OMMISSION
Carrier FEIN
To the Employer:
Carrier File #
A copy of this Form 19 accompanied by a blank Form 18 must be given to the employee. It does
not satisfy the employee’s obligation to file a claim. The filing of this report is required by law.
This form MUST be transmitted to the Industrial Commission through your Insurance Carrier.
To the Employee:
The I.C. File # is the unique identifier for
This Form 19 is not your claim for workers’ compensation benefits. To make a claim, you must complete
this injury. It will be provided by return
and sign the enclosed Form 18 and mail it to Claims Administration, N.C. Industrial Commission, 4335
letter and is to be referenced in all future
correspondence.
Mail Service Center, Raleigh, NC 27699-4335 within two years of the date of your injury or last payment
of medical compensation. For occupational diseases, the claim must be filed within two years of the date
of disability or the date your doctor told you that you have a work-related disease, whichever is later.
The use of this form is required under the provisions of the Workers’ Compensation Act
(
)
-
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
Fax Number
Employer
1.
Give nature of employer’s business
2.
Location of plant where injury occurred
Y
Time
County
Department
State if employer’s premises
Alamance
And
3.
Date of injury
/
/
4.
Day of week
Hour of day
:
A.M.
P.M.
Place
5.
Was employee paid for entire day
6.
Date disability began
/
/
A.M.
P.M.
Y
7.
Date you or the supervisor first knew of injury
/
/
8.
Name of supervisor
9.
Occupation when injured
Person
$
10.
(a) Time employed by you
(b) Wages per hour
Injured
11.
(a) No. hours worked per day
(b) Wages per day
$
(c) No. of days worked per week
(d) Avg. weekly wages w/ overtime
$
(e) If board, lodging, fuel or other advantages were
furnished in addition to wages, estimated value per day, week or month.
$
per
12.
Describe fully how injury occurred and what employee was doing when injured:
Cause
And Nature
Of Injury
(Statement made without prejudice and without vouching for correctness of information)
13.
List all injuries and specify body part involved (e.g. right hand or left hand):
14.
Date & hour returned to work
/
/
at
:
.M.
15.
If so, at what wages
$
per
16.
At what occupation
17.
Employee’s salary continued in full?
Y
N
18.
Was employee treated by a physician
Y
N
Fatal Cases
19.
Has injured employee died
20.
If so, give date of death (Submit Form 29)
/
/
Y
Employer name
Date Completed
/
/
Signed by
Official Title
OSHA 301 Information:
Case Number from Log:
Date Hired:
Time Employee began work on date of incident:
If off-site medical treatment provided,
/
/
:
A.M.
P.M.
answer entire next line.
Name of facility:
Address: Street/City/Zip/Telephone
ER visit?
Overnight stay?
Yes
No
Yes
No
Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to
the extent possible while the information is being used for occupational safety and health purposes.
S
-I
E
C
M
:
ELF
NSURED
MPLOYER OR
ARRIER
AIL TO
NCIC - C
A
LAIMS
DMINISTRATION
F
IC U
O
OR
SE
NLY
M
S
C
4335
AIL
ERVICE
ENTER
R
:______
ESEARCHER
R
, N
C
27699-4335
ALEIGH
ORTH
AROLINA
F
19
ORM
CC:_____________
M
T
:
(919) 807-2500
AIN
ELEPHONE
R
1.2 8/13/12
EV
EC:_____________
D
E
:______
P
1
2
H
:
ATA
NTRY
(800) 688-8349
AGE
OF
ELPLINE
F
19
ORM
W
:
://
.
.
.
/
EBSITE
HTTP
WWW
IC
NC
GOV
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