Nc Form 33 PDF Details

In the realm of workers' compensation in North Carolina, the NC 33 form holds a crucial role, serving as the official request for a hearing when disputes arise over compensation claims. This form is a critical document under the Workers' Compensation Act, ensuring that employees who have suffered injuries while on the job can seek a resolution when there's a disagreement about the benefits they are entitled to receive. It encompasses essential details like the employee's personal information, the date and location of the injury, details about the employer and the insurance carrier, and specifics about the nature of the injury and the compensation sought. Furthermore, the form includes provisions for setting the hearing in a particular county, outlining the reasons for such a choice, while also indicating whether mediation was attempted before escalating the matter to a hearing. Attorneys and parties involved are guided to utilize specific filing options provided, such as electronic submission, mailing, or faxing, ensuring the process is accessible and efficient. Moreover, the form requires a detailed list of witnesses, underscoring the importance of a thorough preparation for the hearing. By filling out the NC 33 form, parties officially communicate their inability to settle a compensation dispute amicably and express their request for the intervention of the North Carolina Industrial Commission to adjudicate their case.

QuestionAnswer
Form NameNc Form 33
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names FORM 33 - Workers Compensation LawyersWorkers Comp ...

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NORTH CAROLINA INDUSTRIAL COMMISSION

IC File #

REQUEST THAT CLAIM BE ASSIGNED FOR HEARING

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

( )

Employee’s Name (LAST NAME)

(FIRST NAME)

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip

(

)

 

(

)

 

Home Telephone

 

Work Telephone

 

฀

M ฀ F

 

/

/

Social Security Number

Sex

 

Date of Birth

Date of injury:

City and county where the injury occurred:

Employer's Name

 

 

Telephone Number

 

 

 

 

 

Employer’s Address

 

City

State

Zip

 

 

 

 

 

Insurance Carrier

 

 

 

 

 

 

 

 

 

Carrier's Address

 

City

State

Zip

(

)

(

)

 

 

Carrier's Telephone Number

 

 

Fax Number

 

Part of body:

Estimated length of hearing:

This case will be set in the county where the injury occurred unless otherwise authorized by the Commission. If the requesting party wants the hearing to be set in a different county, name the county below and the reason for that location.

(County)(Reason for setting)

I, ____________________________________, ฀ Plaintiff/Attorney ฀ Defendant/Attorney, respectfully notify you that the above named

parties have failed to reach an agreement regarding compensation, and I request a hearing.

We have been unable to agree because (State reason with specificity. If appealing an Administrative Order, provide the file date of the Order and the name of the hearing officer who issued the order.):

Employee believes he or she is entitled to the following workers' compensation benefits (check all that apply):

฀Payment of compensation for days missed (give dates):

฀Payment of extended compensation under G.S. 97-29(c) (state first date of disability):

฀Payment of medical expenses/treatment:

฀Payment for permanent partial disability:

฀Payment for permanent and total disability:

฀Payment for scars:

฀Other:_________________________________

Has claimant participated in mediation? ฀ Yes ฀ No

ATTORNEYS:

FILE VIA ELECTRONIC DOCUMENT FILING PORTAL

HTTP://WWW.IC.NC.GOV/DOCFILING.HTML

FORM 33 01/2020

PAGE 1 OF 2

FORM 33

EMPLOYEE FILING OPTIONS:

E-MAIL TO DOCKETS@IC.NC.GOV

FAX TO (919) 715-0282

MAIL TO NCIC-DOCKET SECTION

1236 MAIL SERVICE CENTER

RALEIGH, NC 27699-1236

HELPLINE: (800) 688-8349

WEBSITE: HTTP://WWW.IC.NC.GOV

Below is a list of names of all witnesses, including doctors, whose testimony is to be taken by the requesting party. Addresses must be provided for the doctors listed below.

NAME

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby certify that this case is ready for hearing. When a date of hearing is set, I respectfully request the Commission to send me signed subpoenas for my witnesses. When I receive these subpoenas, I will serve them pursuant to the instructions on Page 2 of the Industrial Commission Form 36.

Signature of Party Requesting Hearing

Printed Name of Party Requesting Hearing

Check one: ฀ Employee, ฀ Employer; ฀ Attorney

 

 

Mailing Address: Street and number, city, state and ZIP Code

Telephone Number:

Date of Notice:

E-mail Address:

Notice to Employees: The original of this form must be sent to the Industrial Commission at the address below or by e-mail to dockets@ic.nc.gov. A copy of the form must be sent to opposing parties.

CERTIFICATE OF SERVICE

I hereby certify that on _________________________, I served a copy of this Form 33 Request for Hearing, together with all

supporting documents, on the following party(ies) by way of

___________________________________________________________.

(U.S. Mail, special delivery mail, e-mail, fax, hand delivery, etc.)

[Note: List name and address of each attorney or party served. Attach a separate sheet if necessary.]

___________________________________________________________________________________________________________

Signature

Printed Name

Date

FORM 33 01/2020

PAGE 2 OF 2

FORM 33

ATTORNEYS:

FILE VIA ELECTRONIC DOCUMENT FILING PORTAL

HTTP://WWW.IC.NC.GOV/DOCFILING.HTML

EMPLOYEE FILING OPTIONS:

E-MAIL TO DOCKETS@IC.NC.GOV

FAX TO (919) 715-0282

MAIL TO NCIC-DOCKET SECTION

1236 MAIL SERVICE CENTER

RALEIGH, NC 27699-1236

HELPLINE: (800) 688-8349

WEBSITE: HTTP://WWW.IC.NC.GOV

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1. Start completing the Nc Form 33 with a group of necessary fields. Note all of the required information and ensure there is nothing forgotten!

Nc Form 33 writing process detailed (part 1)

2. Once your current task is complete, take the next step – fill out all of these fields - County I PlaintiffAttorney, Employee believes he or she is, Payment of compensation for days, Payment of extended compensation, Payment of medical, ATTORNEYS FILE VIA ELECTRONIC, and FORM PAGE OF with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Ways to fill out Nc Form 33 stage 2

3. This third stage will be straightforward - fill in all of the fields in NAME, ADDRESS, I hereby certify that this case is, send me signed subpoenas for my, Signature of Party Requesting, Check one Employee Employer, Printed Name of Party Requesting, Telephone Number, Email Address, Mailing Address Street and number, Date of Notice, and Notice to Employees The original to conclude this part.

Tips on how to fill in Nc Form 33 stage 3

Always be really attentive when completing I hereby certify that this case is and NAME, as this is the section where a lot of people make some mistakes.

4. The following subsection needs your attention in the subsequent areas: CERTIFICATE OF SERVICE, I hereby certify that on I served, supporting documents on the, US Mail special delivery mail, Note List name and address of each, ATTORNEYS FILE VIA ELECTRONIC, FORM, and FORM PAGE OF. Ensure that you type in all of the requested information to go forward.

The right way to fill out Nc Form 33 step 4

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