Nc Form 22 PDF Details

In the wake of an injury on the job, navigating the complexities of workers' compensation claims can feel overwhelming for both employees and employers. Central to this process in North Carolina is the Form 22, a document required under the Workers' Compensation Act, which meticulously records the days worked and earnings of an injured employee. This document serves a pivotal role, offering a detailed account of an employee's work history and compensation in the 52 weeks leading up to the injury. It is imperative not only for calculating the compensation due but also for verifying the employment details provided by the employee and the employer. Detailed within this form are sections for documenting the injured employee's personal information, comprehensive earnings over the specified period, and any non-monetary benefits provided in lieu of wages. Employers are tasked with accurately filling this form, noting changes in job roles or pay rates, and marking days paid in full, including paid leave. Additionally, the form includes essential instructions for its completion and stipulates the legal implications of falsifying information, reinforcing its significance in upholding the integrity of the workers' compensation claims process. Its thorough completion and submission through the designated electronic portal not only streamline the claims process but also ensure that all parties involved adhere to the legal and procedural expectations set forth by the North Carolina Industrial Commission.

QuestionAnswer
Form NameNc Form 22
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform nc 22, nc form 22, workers compensation form 22, form 22 instructions

Form Preview Example

NORTH CAROLINA INDUSTRIAL COMMISSION

 

 

 

 

 

 

IC File #

 

 

STATEMENT OF DAYS WORKED AND EARNINGS OF

Emp. Code #

 

 

 

 

 

INJURED EMPLOYEE

 

 

 

 

Carrier Code #

 

 

 

 

 

 

 

 

 

The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act

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

XXX-XX-

M

F

/ /

Last 4 Digits of SSN

Sex

 

Date of Birth

(

)

-

(

)

-

Carrier's Telephone Number

 

 

Fax Number

 

 

 

 

 

 

Date of Injury: / /

Year:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Amount

20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Earned

Jan.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Feb.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mar.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apr.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

May

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

June

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

July

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aug.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sept.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oct.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nov.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dec.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was this employee given free rent, lodging, or board or other allowances made in lieu of wages?

If so, state weekly value thereof: $

.

.

FORM 22 03/2020

PAGE 1 OF 2

FORM 22

FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML

,

The undersigned employer of

 

 

 

(Name of Employee)

 

who alleges an injury on the

of

,

20

 

(Day)

 

(Month)

(Year)

while in the employment of the undersigned, does hereby certify that the above is a true and correct statement of days worked and earnings of this employee during the 52 weeks immediately preceding the injury (or during the above weeks and parts thereof, if employed for less than 52 weeks) and while engaged in the occupation in which the employee was allegedly injured.

Employer

By

Authorized Signature

/ /20

Date Signed

To Employer: Making a false statement for the purpose of denying workers’

compensation benefits may result in civil or criminal penalties.

INSTRUCTIONS

This form must be completed and filed with the Commission in all cases resulting in death unless maximum compensation rate is stipulated. It must also be filed in any other case if there is a disagreement about earnings or if the Commission requests it.

In preparing this form, place an X in the proper squares to indicate days paid in full. Days the employee is on paid vacation leave and/or paid sick leave should be marked with an X. Leave blank squares to indicate days not paid in full for any reason. Total earnings for each pay period should be placed in the proper column. If the employee's job or pay rate was changed during the reported period, this should be noted, with an indication as to the nature of the change.

The employer code number and the carrier code number, if any, must be inserted in the proper place at the upper right-hand corner of the form.

FORM 22 03/2020

PAGE 2 OF 2

FORM 22

FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML

How to Edit Nc Form 22 Online for Free

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form 22 fillable conclusion process explained (portion 1)

2. When the previous section is completed, go on to type in the applicable details in these: Year, Jan, Feb, Mar, Apr, May, June, July, Aug, Sept, Oct, Nov, Dec, Total, and Was this employee given free rent.

Stage no. 2 for completing form 22 fillable

3. Completing The undersigned employer of who, Day, Name of Employee, Month, Year, while in the employment of the, Employer, Authorized Signature, Date Signed, To Employer Making a false, compensation benefits may result, and INSTRUCTIONS is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

form 22 fillable completion process explained (stage 3)

As for Name of Employee and Month, be sure that you review things here. Those two are certainly the most important ones in the page.

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