Form 28B – Fill Out and Use This PDF

NORTH CAROLINA INDUSTRIAL COMMISSION

IC File #________

REPORT OF EMPLOYER OR CARRIER/ADMINISTRATOR OF	Emp. Code #________
COMPENSATION AND MEDICAL COMPENSATION PAID AND	Carrier Code #________
NOTICE OF RIGHT TO ADDITIONAL MEDICAL COMPENSATION	Carrier File #________
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act	Employer FEIN________

.

1.Date of accident or disability from occupational disease_____________________________.

2.	Salary ฀ was / ฀ was not continued.						Total Dollar Amount
3.	Number of weeks temporary total		from		, through		$_________________
			from		, through		$_________________
4.	Number of weeks temporary partial		from		, through		$_________________
			from		, through		$_________________
5.	Number of weeks permanent partial		from		, through	$_________________

6.Disfigurement amount paid $

7.Death benefits paid $

8.Loss of organ or body part benefits paid $

9.Total of lines 3 through 8, including any attorney fee paid to employee’s attorney $

10.Compromise Settlement Agreement amount $

11.	a. Total medical paid $			Does this include final medical? ฀ Yes / ฀ No
	(Include bills for nursing, doctor, hospital, drugs, etc., but exclude rehabilitation and "medical only" paid)

b.Total rehabilitation paid $

c.Total “medical only” paid $

12.Total of lines 9, 10, 11a, and 11b. $

13.Miscellaneous payments:

Funeral benefits $ Second injury fund $ Hearing Costs $ Expert witness fees $ Other $

14. Has employee returned to work? ฀ Yes / ฀ No If so, on what date?

15. Date last compensation check forwarded

16. Date last medical compensation paid

NAME OF EMPLOYER OR CARRIER/ADMINISTRATOR

SIGNATURE

TITLE

DATE

This form must be filed with the Industrial Commission at the address below, and a copy provided the employee with his last compensation check within 16 days following final payment of compensation and final medical payment.

FOR INDUSTRIAL COMMISSION USE ONLY

Days	____________________
Compensation Paid	$____________________
Medical	$____________________
IC Code:	____________________

IMPORTANT NOTICE TO EMPLOYEE CLAIMING

ADDITIONAL WEEKLY COMPENSATION CHECKS

OR LUMP SUM PAYMENT

If you claim further compensation, you must notify the Industrial Commission in writing within two years from the date of receipt of your last compensation check or your rights to these benefits may be lost.

IMPORTANT NOTICE TO EMPLOYEE

CLAIMING ADDITIONAL MEDICAL BENEFITS

INJURED BEFORE JULY 5, 1994

If your injury occurred before July 5, 1994, you are entitled to medical compensation as long as it is reasonably necessary, related to your workers' compensation case, and authorized by the carrier or the Industrial Commission.

IMPORTANT NOTICE TO EMPLOYEE

CLAIMING ADDITIONAL MEDICAL BENEFITS

INJURED ON OR AFTER JULY 5, 1994

If your injury occurred on or after July 5, 1994, your right to future medical compensation will depend on several factors. Your right to payment of future medical compensation will terminate two years after your employer or carrier/administrator last pays any medical compensation or other compensation, whichever occurs last. If you think you will need future medical compensation, you must apply to the Industrial Commission in writing within two years, or your right to these benefits may be lost. To apply you may also use Industrial Commission Form 18M.

DEFINITION OF MEDICAL COMPENSATION

The term "medical compensation" means medical, surgical, hospital, nursing and rehabilitative services, and medicines, sick travel, and other treatment, including medical and surgical supplies, as may reasonably be required to effect a cure or give relief, and for such additional time, as in the judgment of the Industrial Commission, will tend to lessen the period of disability; and any original artificial members as may reasonably be necessary at the end of the healing period, and the replacement of such artificial members when reasonably necessitated by ordinary use or medical circumstances. N.C. Gen. Stat. § 97-2(19).

NEED ASSISTANCE?

If you have questions or need help and you do not have an attorney, you may contact the Industrial Commission’ Ombudsman at

(800) 688-8349