North Carolina > Workers Comp
Application To Reinstate Payment Of Disability Compensation 23 - North Carolina
| Application To Reinstate Payment Of Disability Compensation Form. This is a North Carolina form and can be used in Workers Comp . |
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North Carolina Industrial Commission IC File # APPLICATION TO REINSTATE PAYMENT OF DISABILITY COMPENSATION (G.S. 97-18(k)) Emp. Code # Carrier Code # Carrier File # Employer FEIN ( Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address City City ) Telephone Number State Zip ( ) M F ( / ) State Zip Home Telephone Social Security Number Sex Work Telephone / ( ) ( ) Fax Number Date of Birth Carrier's Telephone Number The employee in this claim has applied for reinstatement of compensation. The employer or carrier must respond to this Application by completing Section B of this Form and returning one copy to the Industrial Commission within 10 days of receipt of this Form from the Industrial Commission. If the employer or carrier does not respond to this Application, an Order may be issued reinstating compensation. If you timely object to reinstatement, the matter will be scheduled for informal telephonic hearing. IMPORTANT NOTICE TO EMPLOYER: SECTION A. TO BE COMPLETED BY THE EMPLOYEE: 1. Date of injury by accident or occupational disease: _______________________________________________________________ 2. Nature and extent of injury or occupational disease: ______________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 3. (a) Has your claim been accepted or determined to be compensable by the Industrial Commission: Yes: (b) If so, how: Form 21 Form 60 Form 63 Opinion and Award No: Other________________________________________________ 4. Number of weeks compensation already paid: _________ From:_______/________/_______ To:________/________/________ 5. Date from which seeking compensation:________________________________________________________________________ 6. Application is made to reinstate compensation on the grounds that:___________________________________________________ YOU MUST ATTACH DOCUMENTATION TO SUPPORT THIS APPLICATION FOR REINSTATEMENT OF COMPENSATION. NUMBER OF PAGES ATTACHED: ________________ GIVE A TELEPHONE NUMBER AT WHICH YOU CAN BE REACHED IF AN INFORMAL HEARING IS SCHEDULED, FROM MONDAY THROUGH FRIDAY BETWEEN 8:00 A.M. AND 5:00 P.M.: ______________________. THE INDUSTRIAL COMMISSION WILL NOTIFY YOU IF AN INFORMAL HEARING IS SCHEDULED. 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 SENT TO THE EMPLOYER OR CARRIER/ADMINISTRATOR AT: (ADDRESS/FAX NO):____________________________________________________________________________________________ SIGNATURE OF EMPLOYEE OR ATTORNEY:____________________________________________________DATE:___________________ FORM 23 8/11 PAGE 1 OF 2 FORM 23 SEND TO: NCIC - EXECUTIVE SECRETARY 4333 MAIL SERVICE CENTER RALEIGH, NC 27699-4333 MAIN TELEPHONE: (919) 807-2501 FAX NUMBER: (919) 733-5389 HELPLINE: (800) 688-8349 WEBSITE: http://www.ic.nc.gov/ American LegalNet, Inc. www.FormsWorkFlow.com I.C. NO. ___________ SECTION B. TO BE COMPLETED BY THE EMPLOYER OR CARRIER/ADMINISTRATOR 1. THE EMPLOYER/CARRIER MUST COMPLETE EITHER 1.(a) OR 1.(b) (a) If reinstatement of compensation is not contested, complete the following: Compensation in the amount of $__________ per week was or will be reinstated from __________/__________/__________ commencing on: _________/___________/__________ If compensation is reinstated on a date other than the date requested by the employee in Section A.5., please explain:________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ (b) Compensation should not be reinstated because:____________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 2. (a) Specify whether this claim has been accepted, denied or determined compensable by the Industrial Commission:_________ ______________________________________________________________________________________________________ (b) How: Form 61 Form 21 Form 60 Form 63 Opinion and Award Other___________________________________________________________ 3. If compensation has been paid, provide the number of weeks: _______From:______/______/______To:______/______/______ IF REINSTATEMENT OF COMPENSATION IS CONTESTED, 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. ______________________ AND A FACSIMILE NUMBER OR E-MAIL ADDRESS FOR SERVICE OF THE HEARING NOTICE AND ANY OTHER CORRESPONDENCE: IN ADDITION TO FILING THE ORIGINAL OF THIS RESPONSE WITH THE INDUSTRIAL COMMISSION, I HEREBY CERTIFY THAT A COPY OF THIS RESPONSE, TOGETHER WITH SUPPORTING DOCUMENTS, WAS SENT TO THE EMPLOYEE OR THE EMPLOYEE'S ATTORNEY OF RECORD, IF ANY, AT (ADDRESS/FAX NO:)_________________________________________________________________________________________ ________________________________________________________________________________________________________ ON _______________________________________________________________. SIGNATURE OF EMPLOYER, CARRIER/ADMINISTRATOR OR ATTORNEY:_________________________________________________________________________DATE:__________________ FORM 23 8/11 PAGE 2 OF 2 FORM 23 SEND TO: NCIC - EXECUTIVE SECRETARY 4333 MAIL SERVICE CENTER RALEIGH, NC 27699-4333 MAIN TELEPHONE: (919) 807-2501 FAX NUMBER: (919) 733-5389 HELPLINE: (800) 688-8349 WEBSITE: http://www.ic.nc.gov/ American LegalNet, Inc. www.FormsWorkFlow.com
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