North Carolina > Workers Comp
Claim By Employee Representative Or Dependent For Benefits For Lung Disease 18B - North Carolina
| Claim By Employee Representative Or Dependent For Benefits For Lung Disease Form. This is a North Carolina form and can be used in Workers Comp . |
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North Carolina Industrial Commission IC File # CLAIM BY EMPLOYEE , REPRESENTATIVE , OR DEPENDENT Emp. Code # FOR BENEFITS FOR LUNG DISEASE Carrier Code # INCLUDING ASBESTOSIS, SILICOSIS , AND BYSSINOSIS (G.S. 97-53) Employer FEIN The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act M F / / Employees Name Social Security Number Sex Date of Birth Address If Employee is deceased, list Personal Representative City State Zip Spouses Name ( ) ( ) Employees Home Telephone Work Telephone Name of Attorney if represented PRINT OR TYPE ALL ANSWERS Notice is hereby given, as required by law, that the above-named employee sustained an occupational disease caused by exposure to: cotton dust ; silica ; asbestos ; or other substance and, if known, state substance: .Date of diagnosis By: Dr. Attach diagnosing medical records. Employer-Defendants Attach additional pages if necessary Employer Name: Telephone: ( ) Dates of Employment Address: Location of Job(s) City State Zip Employer Name: Telephone: ( ) Dates of Employment Address: Location of Job(s) City State Zip Employer Name: Telephone: ( ) Dates of Employment Address: Location of Job(s) City State Zip Employer Name: Telephone: ( ) Dates of Employment Address: Location of Job(s) City State Zip IT IS REQUIRED THAT BOTH PAGES OF THIS FORM BE COMPLETED IN ORDER TO PROCESS THIS CLAIM MAIL TO: NCIC - CLAIMS SECTION FORM 18B 4335 MAIL SERVICE CENTER 5/02 FORM 18B RALEIGH, NORTH CAROLINA 27699-4335 PAGE 1 OF 2 MAIN TELEPHONE (919) 807-2500 OMBUDSMAN : (800) 688-8349 <<<<<<<<<********>>>>>>>>>>>>> 2 Employment History, Beginning With Most Recent Employment (Attach additional pages if necessary): Employer From / To: Employers Type of Business Employees Job Title If you were exposed to the listed substance(s) while working for this employer, describe in detail the exposures: Employer From / To: Employers Type of Business Employees Job Title If you were exposed to the listed substance(s) while working for this employer, describe in detail the exposures: Employer From / To: Employers Type of Business Employees Job Title If you were exposed to the listed substance(s) while working for this employer, describe in detail the exposures: List the names and addresses of all family physicians, treating physicians and hospitals that have provided medical services or treatment to you over a 20 year period prior to the filing of this claim. Year Name Address (City) Purpose for which treated (if known) I hereby authorize the above named medical sources to disclose medical records (including images such as x-rays, CT scans, MRIs, sonograms, etc.) regarding my treatment, hospitalization, and/or outpatient care for any condition during the period(s) identified above to all parties (including insurance companies) or State agencies that may review my application for compensation. I also hereby authorize that a photocopy of this authorization be accepted with the same authority as this original. The information disclosed will be used in connection with my claim for benefits under the Workers Compensation Act. I understand this authorization will automatically expire when my application for benefits is finally decided. ( ) Telephone Number Signature of (Check One) Employee, Attorney, Representative, or Dependent Address City State Zip Date Completed Employee should return original of this form to the Industrial Commission, furnish his/her employer with one signed copy, and retain a copy. MAIL TO: NCIC - CLAIMS SECTION FORM 18B 4335 MAIL SERVICE CENTER 5/02 FORM 18B RALEIGH, NORTH CAROLINA 27699-4335 PAGE 2 OF 2 MAIN TELEPHONE (919) 807-2500 OMBUDSMAN : (800) 688-8349
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