In the labyrinth of paperwork that guides the process of managing workers' compensation claims, the 24 Ncic form emerges as a pivotal document within the jurisdiction of the North Carolina Industrial Commission. This form, formally titled as the "Application to Terminate or Suspend Payment of Compensation," serves as a critical notification mechanism, whereby employers or insurance carriers can propose the cessation or adjustment of compensation to an employee under specific circumstances outlined in the Workers' Compensation Act, specifically under G.S. 97-18.1. It succinctly captures essential details about the employee, the employer, the nature of the injury, and the compensation paid so far, offering a structured way to communicate vital information. The form also succinctly warns employees about the imminent stoppage of their benefits, urging them to object promptly should they find the decision unfounded, thereby emphasizing the importance of speed and accuracy in their response. Additionally, it hints at the possibility of an informal hearing by the Industrial Commission, creating a provisional path for dispute resolution. Detailed instructions on the form guide both the employer or carrier/administrator and the employee through the process, ensuring compliance and facilitating a smoother procedural flow through the often-complex workers’ compensation system. This form not only facilitates administrative efficiency but also stands as a safeguard for ensuring that the employees' rights are considered in the deliberation to adjust their workers' compensation benefits.
| Question | Answer |
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| Form Name | Form 24 Ncic |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | HTTP, WWW, RALEIGH, indemnity |
North Carolina Industrial Commission
IC File #
APPLICATION TO TERMINATE OR SUSPEND PAYMENT OF
COMPENSATION (G.S.
Emp. Code #
Carrier Code # Carrier File #
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act |
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Employee’s Name
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IMPORTANT NOTICE TO EMPLOYEE: YOUR BENEFITS MAY BE STOPPED UNLESS YOU OBJECT IMMEDIATELY. IF YOU BELIEVE YOUR |
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BENEFITS SHOULD NOT BE STOPPED, YOU MUST FILL OUT SECTION B. OF THIS FORM AND RETURN ONE COPY OF THIS FORM TO THE INDUSTRIAL |
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COMMISSION. IF THE INDUSTRIAL COMMISSION HAS NOT RECEIVED THE COMPLETED COPY OF THIS FORM FROM YOU BY |
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YOUR BENEFITS MAY BE STOPPED WITHOUT FURTHER NOTICE TO YOU. IF YOU OBJECT, YOU MAY HAVE THE RIGHT TO AN INFORMAL HEARING BY THE INDUSTRIAL COMMISSION BEFORE YOUR BENEFITS CAN BE STOPPED. (THE DATE TO BE INSERTED ABOVE BY THE EMPLOYER OR CARRIER/ADMINISTRATOR SHALL BE 17 DAYS AFTER THIS APPLICATION WAS MAILED TO THE INDUSTRIAL COMMISSION.)
SECTION A. TO BE COMPLETED BY THE EMPLOYER OR CARRIER/ADMINISTRATOR:
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Date of injury by accident : |
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Date disability began : |
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Nature and extent of injury: |
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Number of weeks compensation paid: |
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From : |
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To : |
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4.Total amount of indemnity compensation paid to date: $
5.Check applicable box(s):
a. An agreement was approved by the Industrial Commission on
b. The employer admitted employee's right to compensation pursuant to N.C. Gen. Stat. §
c. The employer paid compensation to employee without contesting claim within the
statutory period provided under N.C. Gen. Stat. §
d. Other:
6.Application is made to terminate or suspend compensation to the employee on the grounds that
7. Check box if employee is in managed care.
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MAIL TO: NCIC - EXECUTIVE SECRETARY |
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FORM 24 |
4333 MAIL SERVICE CENTER |
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RALEIGH, NC |
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2/01 |
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PAGE 1 OF 2 |
MAIN TELEPHONE: (919) |
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FORM 24 |
HELPLINE: (800) |
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WEBSITE: HTTP://WWW.IC.NC.GOV/ |
In addition to filing the original of this application and supporting documents with the Industrial Commission, I hereby certify that a copy of this application, together with all supporting documents, was mailed to the employee at
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and employee's attorney of record, if any, on |
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The attached documents consist of |
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(number) pages. |
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SIGNATURE OF EMPLOYER OR CARRIER/ADMINISTRATOR |
PRINTED NAME |
TELEPHONE NUMBER |
DATE |
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TO BE COMPLETED BY THE EMPLOYEE
SECTION B. IF YOU THINK YOUR COMPENSATION SHOULD NOT BE STOPPED, YOU SHOULD COMPLETE THIS SECTION.
1.I do not think my compensation should be stopped because:
2.Enclose and specify the number of pages of documents the Industrial Commission should consider: (number).
3.Give a telephone number at which you can be reached when the informal hearing is scheduled, from Monday through Friday
between 8:00 a.m. and 5:00 p.m.: |
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. The Industrial Commission will notify you of the date and time of the hearing. |
SIGNATURE OF EMPLOYEE |
WITNESS |
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If you need assistance in completing this form, you may contact the Industrial Commission at (800)
Office of the Executive Secretary at (919)
documents you have not been able to obtain.
EMPLOYEE: SEND A COPY OF THIS FORM AND SUPPORTING DOCUMENTS TO THE EMPLOYER AND
CARRIER/ADMINISTRATOR FROM WHOM YOU ARE RECEIVING COMPENSATION. SEND THE ORIGINAL TO:
INDUSTRIAL COMMISSION, OFFICE OF THE EXECUTIVE SECRETARY, 4333 MAIL SERVICE CENTER, RALEIGH NC
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MAIL TO: NCIC - EXECUTIVE SECRETARY |
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FORM 24 |
4333 MAIL SERVICE CENTER |
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RALEIGH, NC |
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2/01 |
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PAGE 2 OF 2 |
MAIN TELEPHONE: (919) |
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FORM 24 |
HELPLINE: (800) |
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WEBSITE: HTTP://WWW.IC.NC.GOV/ |