Claim By Employee Representative Or Dependent For Benefits For Lung Disease {18B}

FORM 18B 10/2017 PAGE 1 OF 2 E-MAIL TO:MAIL TO: FORMS@IC.NC.GOV NCIC - CLAIMS SECTION 1235 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-1235 MAIN TELEPHONE (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/ FORM 18B North Carolina Industrial Commission IC File #CLAIM BY EMPLOYEE, REPRESENTATIVE, OR DEPENDENT Emp. Code # FOR BENEFITS FOR LUNG DISEASE Carrier Code # I NCLUDING ASBESTOSIS, SILICOSIS, AND BYSSINOSIS (G.S. 247 97-53) Employer FEIN The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act M F / / Employee222s Name Social Security Number Sex Date of Birth A ddress If Employee is deceased, list Personal Representative City State ZipSpouse222s Name ( ) ( ) Employee's Home Telephone Work TelephoneName 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 b y exposure to: cotton dust ; silica ; asbestos ; or other substance and, if known, state substance: . Date of dia g nosis B y : Dr. A ttach dia g nosin g medical records. Employer-Defendants Attach additional pages if necessary Employer Name: Telephone:( ) Dates of Employment A ddress: Location of Job(s) City State Zip Employer Name: Telephone:( ) Dates of Employment A ddress: Location of Job(s) City State Zip Emplo y er Name: Telephone: ( ) Dates of Emplo y ment A ddress: Location of Job(s) City State Zip Emplo y er Name: Telephone: ( ) Dates of Emplo y ment A ddress: Location of Job(s) City State Zip American LegalNet, Inc. www.FormsWorkFlow.com FORM 18B 10/2017 PAGE 2 OF 2 E-MAIL TO:MAIL TO: FORMS@IC.NC.GOV NCIC - CLAIMS SECTION 1235 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-1235 MAIN TELEPHONE (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/ FORM 18B IT IS REQUIRED THAT BOTH PAGES OF THIS FORM BE COMPLETED IN ORDER TO PROCESS THIS CLAIM Emplo y ment Histor y , Be g innin g with Most Recent Emplo y ment ( Attach additional pa g es if necessar y) : Employer From / To: Employer222s Type of Business Employee222s Job Title If you were exposed to the listed substance(s) while working for this employer, describe in detail the exposures: Employer From / To: Employer222s Type of Business Employee222s Job Title If you were exposed to the listed substance(s) while working for this employer, describe in detail the exposures: Employer From / To: Employer222s Type of Business Employee222s 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. Yea r Name Address ( Cit y) 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. ( ) Signature of (Check One) Employee, Attorney, Representative, or Dependent Telephone Number 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. American LegalNet, Inc. www.FormsWorkFlow.com