In the realm of workers' compensation, the 25R Form emerges as a pivotal document mandated by the provisions of the Workers' Compensation Act, specifically within the jurisdiction of North Carolina. This form is meticulously designed to evaluate the extent of an employee's permanent impairment resulting from a work-related injury. It encompasses a comprehensive assessment ranging from the designated body parts such as thumbs, fingers, and back, to other areas including dental, vision, and hearing impairments. The process it outlines intends not just to document the percentage of impairment experienced by the employee but also to determine whether the employee has reached maximum medical improvement and if they have been released with restrictions. The form necessitates the detailed input of the evaluating physician, alongside vital employee information such as social security number, address, and the specific details of the injury sustained. Moreover, it stipulates guidelines for computing compensation for amputations, thereby providing a structured approach to quantifying compensation benefits. The requirement for this form underscores the legal framework aimed at ensuring fair compensation for employees who have suffered work-related injuries, promoting a gesture of accountability from employers and insurance carriers. Detailed instructions for the submission of the completed form highlight the formal process involved, ensuring both the employee and their attorney (if applicable) receive a copy, with the original being directed to the Industrial Commission.
| Question | Answer |
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| Form Name | Form 25R |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 25r form, 25 r, 25 r form, form 25r pdf north carolina |
NORTH CAROLINA INDUSTRIAL COMMISSIONIC File #
EVALUATION FOR PERMANENT IMPAIRMENT |
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The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act |
Employer FEIN |
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Employee’s Name
Address
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Social Security Number |
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Date of Birth |
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Date of Injury:
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Employer's Name |
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Employer’s Address |
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Insurance Carrier |
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Carrier's Address |
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EMPLOYEE'S
MEMBER |
% OF IMPAIRMENT |
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(IF AMPUTATION, DESCRIBE ON REVERSE.) |
1)Thumb
2)Index Finger
3)Middle Finger
4)Ring Finger
5)Little Finger
6)Great Toe
7)Toes (other than great toe)
8)Hand
9)Arm
10)Foot
11)Leg
12)Back
In regard to this rated body part:
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Is employee at maximum medical improvement? |
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Was employee released with restrictions? |
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Physician Signature
Printed Name
Fed. Tax ID Number
Date
Address
TEETH: Age of employee:
List all crowns by number :
List all extractions by number :
Has dental work been completed? Yes No
VISION: List vision reading without the use of a corrective lens.
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Near: |
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HEARING: Scale used: |
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Percentage of loss: Right ear |
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PLEASE ATTACH AUDIOGRAMS AND CALCULATIONS OF HEARING LOSS |
Left ear |
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OTHER: Permanent injury to or impairment of any other organ or part of body (identify) : |
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Disfigurement: Yes No |
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Location: face head |
body |
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FORM 25R |
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NCIC - CLAIMS SECTION |
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FORM |
25R |
4335 MAIL SERVICE CENTER |
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8/1/08 |
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RALEIGH, NORTH CAROLINA |
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PAGE 1 OF 2 |
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MAIN TELEPHONE: (919) |
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HELPLINE: (800)
WEBSITE: HTTP://WWW.IC.NC.GOV/
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Rule 405 |
Comments: |
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Computation of Compensation for Amputations |
(1)Amputation of any portion of the bone of a distal phalange of a finger or toe at or distal to the visible base of the nail will be considered as equivalent to the loss of
(2)Amputation of any portion of the bone of the distal phalange of a finger or toe proximal to the visible base of the nail will be considered as equivalent to the loss of
(3)Amputation through the forearm at a point so distal to the elbow as to permit satisfactory use of a prosthetic appliance with retention of full natural elbow function shall be considered amputation of the hand. Otherwise, it shall be considered amputation of the arm.
(4)Amputation through the lower leg at a point so distal to the knee as to permit satisfactory use of a prosthetic appliance with retention of full natural knee function shall be considered amputation of the foot. Otherwise, it shall be considered amputation of the leg.
A copy of this form must be provided to the employee or the employee’s attorney of record if any.
The original should be mailed to the Industrial Commission at the address below.
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FORM 25R |
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NCIC - CLAIMS SECTION |
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FORM 25R |
4335 MAIL SERVICE CENTER |
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8/1/08 |
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RALEIGH, NORTH CAROLINA |
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PAGE 2 OF 2 |
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MAIN TELEPHONE: (919) |
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HELPLINE: (800) |
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WEBSITE: HTTP://WWW.IC.NC.GOV/ |