Employees Request That Compensation Be Reinstated After Unsuccessful Trial Return To Work {28U} | Pdf Fpdf Doc Docx | North Carolina

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Employees Request That Compensation Be Reinstated After Unsuccessful Trial Return To Work {28U} | Pdf Fpdf Doc Docx | North Carolina

Employees Request That Compensation Be Reinstated After Unsuccessful Trial Return To Work {28U}

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 # Emp. Code # Carrier Code # Employer FEIN EMPLOYEE'S REQUEST THAT COMPENSATION BE REINSTATED AFTER UNSUCCESSFUL TRIAL RETURN TO WORK (G.S. § 97-32.1) 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 ) 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 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 PHYSICIAN'S STATEMENT This is to certify that the employee is unable to continue the trial return to work due to the employee's injury for which compensation has been paid. My medical specialty is: SIGNATURE OF AUTHORIZED TREATING PHYSICIAN ADDRESS CITY PRINTED NAME STATE DATE 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. EMPLOYEE'S 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. SEND TO: FORM 28U 02/02016 PAGE 1 OF 1 EXECSEC@IC.NC.GOV OFFICE OF THE EXECUTIVE SECRETARY FORM 28U 4333 MAIL SERVICE CENTER RALEIGH, NC 27699-4333 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com

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