Application To Reinstate Payment Of Disability Compensation {23}

FORM 23 10/2017 PAGE 1 OF 2 A TTORNEYS/CARRIERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML EMPLOYEE FILING OPTIONS: E-MAIL TO EXECSEC@IC.NC.GOV FAX TO (919) 715-0282 MAIL TO NCIC-EXECUTIVE SECRETARY 1236 MAIL SERVICE CENTER RALEIGH, NC 27699-1236 HELPLINE: (800) 688-8349 WEBSITE: HTTP:/ / WWW.IC.NC.GOV FORM 23 North Carolina Industrial Commission IC File # A PPLICATION TO REINSTATE PAYMENT Emp. FEIN # OF DISABILITY COMPENSATION (G.S. 247 97-18(k)) Carrier FEIN # Carrier File # ( ) Employee222s Name Employer's Name Telephone Number A ddress Employer222s Address City State Zip City State ZipInsurance Carrier ( ) ( ) Home Telephone Work TelephoneCarrier's Address City State Zip XXX-XX- M F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth Carrier's Telephone Number Fax Number IMPORTANT NOTICE TO EMPLOYER: The employee in this claim has applied for reinstatement of compensation. If the employer or carrier believes that compensation should not be reinstated, the employer or carrier must respond to this Application by completing Section B of this Form and returning one copy to the Industrial Commission. If the Industrial Commission has not received the completed copy of this Form from the employer or carrier by , an Order may be issued reinstating compensation. If the employer or carrier timely objects to reinstatement, the matter will be scheduled for informal telephonic hearing. (The date to be inserted above by the employee shall be 17 days after this Application was sent to the employer or carrier and Industrial Commission, whether by mail, facsimile, or e-mail.) SECTION A. TO BE COMPLETED BY THE EMPLOYEE: 1. Date of in j u r y b y 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 bythe Industrial Commission: Yes: No: (b) If so, how: Form 21 Form 60 Form 63 Opinion and Award Other 4. Number of weeks compensation alread y paid: From:// To:// 5. Date from which seekin g compensation: 6. A pplication is made to reinstate compensation on the g rounds 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: American LegalNet, Inc. www.FormsWorkFlow.com FORM 23 10/2017 PAGE 2 OF 2 A TTORNEYS/CARRIERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML EMPLOYEE FILING OPTIONS: E-MAIL TO EXECSEC@IC.NC.GOV FAX TO (919) 715-0282 MAIL TO NCIC-EXECUTIVE SECRETARY 1236 MAIL SERVICE CENTER RALEIGH, NC 27699-1236 HELPLINE: (800) 688-8349 WEBSITE: HTTP:/ / WWW.IC.NC.GOV FORM 23 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 followin g : 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 EMPLOYEE222S ATTORNEY OF RECORD, IF ANY, AT (ADDRESS/FAX NO:) ON . SIGNATURE OF EMPLOYER, CARRIER/ADMINISTRATOR OR A TTORNEY:DATE: American LegalNet, Inc. www.FormsWorkFlow.com