Application To Terminate Or Suspend Payment Of Compensation {24} | Pdf Fpdf Doc Docx | North Carolina

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Application To Terminate Or Suspend Payment Of Compensation {24} | Pdf Fpdf Doc Docx | North Carolina

Application To Terminate Or Suspend Payment Of Compensation {24}

This is a North Carolina form that can be used for Workers Comp.

Alternate TextLast updated: 3/30/2016

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North Carolina Industrial Commission IC File # APPLICATION TO TERMINATE OR SUSPEND PAYMENT OF COMPENSATION (G.S. § 97-18.1) The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address Emp. Code # Carrier Code # Carrier File # Employer FEIN ( ) Telephone Number City State Zip ( ) M F ( / ) City State Fax Number Zip Home Telephone Social Security Number Sex Work Telephone / ( ) ( ) Date of Birth Carrier's Telephone Number IMPORTANT NOTICE TO EMPLOYEE: YOUR BENEFITS MAY BE STOPPED UNLESS YOU OBJECT IMMEDIATELY. IF YOU BELIEVE YOUR BENEFITS SHOULD NOT BE STOPPED, YOU MUST FILL OUT SECTION B. OF THIS FORM AND RETURN ONE COPY OF THIS FORM TO THE INDUSTRIAL COMMISSION. IF THE INDUSTRIAL COMMISSION HAS NOT RECEIVED THE COMPLETED COPY OF THIS FORM FROM YOU BY , YOUR BENEFITS MAY BE STOPPED WITHOUT FURTHER NOTICE TO YOU. IF YOU OBJECT, YOU MAY HAVE THE RIGHT TO AN INFORMAL HEARING BY THE INDUSTRIAL COMMISSION BEFORE YOUR BENEFITS CAN BE STOPPED. (THE DATE TO BE INSERTED ABOVE BY THE EMPLOYER OR CARRIER/ADMINISTRATOR SHALL BE AT LEAST 17 DAYS AFTER THIS APPLICATION WAS ELECTRONICALLY FILED WITH THE INDUSTRIAL COMMISSION.) SECTION A. TO BE COMPLETED BY THE EMPLOYER OR CARRIER/ADMINISTRATOR: Date disability began : 1. Date of injury by accident : 2. Nature and extent of injury: 3. Number of weeks compensation paid: 4. Total amount of indemnity compensation paid to date: $ From : To : 5. Check applicable box(s): a. An agreement was approved by the Industrial Commission on b. The employer admitted employee's right to compensation pursuant to N.C. Gen. Stat. § 97-18(b). c. The employer paid compensation to employee without contesting claim within the statutory period provided under N.C. Gen. Stat. § 97-18(d). d. Other: 6. Application is made to terminate or suspend compensation to the employee on the grounds that 7. Check box if employee is in managed care. ATTORNEYS/CARRIERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML FORM 24 02/2016 PAGE 1 OF 2 FORM 24 EMPLOYEE FILING OPTIONS: E-MAIL TO EXECSEC@IC.NC.GOV FAX TO (919) 715-0282 MAIL TO NCIC-EXECUTIVE SECRETARY 4333 MAIL SERVICE CENTER RALEIGH, NC 27699-4333 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com In addition to filing this application and supporting documents with the Industrial Commission, I hereby certify that a copy of this application, together with all supporting documents, was served on the employee by Standard U.S. Mail, at: (address) (city, state, zip) OR on the employee's attorney of record, if any, by e-mail or facsimile to: ___________________________________________________ (email address or fax number served) On the day of: ________________________________________ (date) The attached documents consist of _____ pages. (number) SIGNATURE OF EMPLOYER OR CARRIER/ADMINISTRATOR PRINTED NAME TELEPHONE NUMBER DATE TO BE COMPLETED BY THE EMPLOYEE SECTION B. IF YOU THINK YOUR COMPENSATION SHOULD NOT BE STOPPED, YOU SHOULD COMPLETE THIS SECTION. 1. I do not think my compensation should be stopped because: 2. Enclose and specify the number of pages of documents the Industrial Commission should consider: (number). 3. 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.: . The Industrial Commission will notify you of the date and time of the hearing. SIGNATURE OF EMPLOYEE DATE If you need assistance in completing this form, you may contact the Industrial Commission at (800) 688-8349. You must contact the Office of the Executive Secretary at (919) 807-2657 to obtain an extension of time in which to submit medical records, or to obtain documents you have not been able to obtain. EMPLOYEE: SEND A COPY OF THIS FORM AND SUPPORTING DOCUMENTS TO THE EMPLOYER AND CARRIER/ADMINISTRATOR FROM WHOM YOU ARE RECEIVING COMPENSATION. FILE THE ORIGINAL WITH THE INDUSTRIAL COMMISSION AS INSTRUCTED AT THE BOTTOM OF THE FORM. ATTORNEYS/CARRIERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML FORM 24 02/2016 PAGE 2 OF 2 FORM 24 EMPLOYEE FILING OPTIONS: E-MAIL TO EXECSEC@IC.NC.GOV FAX TO (919) 715-0282 MAIL TO NCIC-EXECUTIVE SECRETARY 4333 MAIL SERVICE CENTER RALEIGH, NC 27699-4333 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com

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