North Carolina > Workers Comp
Employees Request That Compensation Be Reinstated After Unsuccessful Trial Return To Work 28U - North Carolina
| Employees Request That Compensation Be Reinstated After Unsuccessful Trial Return To Work Form. This is a North Carolina form and can be used in Workers Comp . |
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North Carolina Industrial Commission IC File # EMPLOYEE S REQUEST THAT COMPENSATION BE Emp. Code # REINSTATED AFTER UNSUCCESSFUL TRIAL RETURN Carrier Code # TO WORK (G.S. 97-32.1) Employer FEIN The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act ( ) Employees Name Employers Name Telephone Number Address Employers Address City State Zip City State Zip Insurance Carrier ( ) ( ) Home Telephone Work Telephone Carriers Address City State Zip M F / / ( ) ( ) Social Security Number Sex Date of Birth Carriers Telephone Number Fax Number SECTION A. EMPLOYEE: COMPLETE AND MAIL TO EMPLOYER AND CARRIER /ADMINISTRATOR, AND TO THE INDUSTRIAL COMMISSION AT THE ADDRESS BELOW: 1. I request that my total disability compensation be resumed immediately. I had a trial return to work with (name of employer) from (date first worked) until (date last worked). The date of my injury by accident or the date of disability from my occupational disease was 2. Explain in detail the reasons you are no longer working: 3. The employee MUST obtain the following from an authorized treating physician: TREATING PHYSICIANS STATEMENT This is to certify that the employee is unable to continue the trial return to work due to the employees injury for which compensation has been paid. My medical specialty is: S IGNATURE OF AUTHORIZED TREATING PHYSICIAN PRINTED NAME DATE ADDRESS CITY STATE ZIP IF RETURN TO WORK WAS WITH THE EMPLOYER FROM WHOM YOU HAVE RECEIVED WORKERS COMPENSATION, SIGN HERE AND DO NOT COMPLETE THE REMAINDER OF THIS FORM. IF RETURN TO WORK WAS WITH A DIFFERENT EMPLOYER, COMPLETE SECTION B BELOW. SIGNATURE OF EMPLOYEE DATE SECTION B. EMPLOYEES RELEASE OF EMPLOYMENT INFORMATION I hereby request and authorize my last employer, (Name and address of last employer) to release to my prior employer and carrier/administrator listed above, or their attorney of record, the following information relating to my trial return to work: first and last date worked, total wages earned, and the reasons this employee is no longer so employed. READ BEFORE SIGNING SIGNATURE OF EMPLOYEE DATE SEND A COPY OF THIS FORM TO THE EMPLOYER AND CARRIER/ADMINISTRATOR FROM WHOM YOU WERE RECEIVING WORKERS COMPENSATION. SEND THE ORIGINAL TO THE INDUSTRIAL COMMISSION AT THE ADDRESS BELOW . MAIL TO: OFFICE OF THE EXECUTIVE SECRETARY FORM 28U 4333 MAIL S ERVICE CENTER 6/02 R ALEIGH, NC 27699-4333 PAGE 1 OF 1 MAIN TELEPHONE: (919) 807-2500 FORM 28U OMBUDSMAN: (800) 688-8349
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