North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter L - INDUSTRIAL COMMISSION FORMS › Section .0100 - WORKERS' COMPENSATION FORMS › Section 23L .0103 - FORM 26A - EMPLOYER'S ADMISSION OF EMPLOYEE'S RIGHT TO PERMANENT PARTIAL DISABILITY

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The parties to
				  a workers' compensation claim shall use the following Form 26A, Employer's
				  Admission of Employee's Right to Permanent Partial Disability, for agreements
				  regarding the employee's entitlement to and the employer's payment of
				  compensation for permanent partial disability pursuant to
				  G.S.
				  97-31. Additional issues agreed upon by the
				  parties, such as election of payment of temporary partial disability pursuant
				  to G.S.
				  97-30, may also be included on the form. This
				  form is necessary to comply with Rule
				  11 NCAC
				  23A .0501, where applicable. The Form 26A,
				  Employer's Admission of Employee's Right to Permanent Partial Disability, shall
				  read as follows:
North Carolina Industrial Commission
Employer's Admission of Employee's Right to Permanent
					 Partial Disability
(G.S. 97-31)
IC File # __________
Emp. Code # __________
Carrier Code # __________
Carrier File # __________
The Use Of This Form Is Required Under The Provisions of
					 The Workers' Compensation Act
____________________________________________________________
Employee's Name
____________________________________________________________
Address
____________________________________________________________
City State Zip
____________________________________________________________
Home Telephone Work Telephone
Last 4 digits of
Social Security
					 Number: _______ Sex: [] M [] F Date of Birth: _______
____________________________________________________________
Employer's Name Telephone Number
____________________________________________________________
Employer's Address City State Zip
____________________________________________________________
Insurance Carrier
____________________________________________________________
Carrier's Address City State Zip
____________________________________________________________
Carrier's Telephone Number Carrier's Fax Number
WE, THE UNDERSIGNED, DO HEREBY AGREE AND STIPULATE AS
					 FOLLOWS:
1. All the parties hereto are
				  subject to and bound by the provisions of the Workers' Compensation Act and
				  ______________________ is the Carrier/Administrator for the Employer.
2. The employee sustained an injury by
				  accident or the employee contracted an occupational disease arising out of and
				  in the course of employment on _____________________.
3. The injury by accident or occupational
				  disease resulted in the following injuries:
				  ______________________________________________________________________________.
4. The employee [] was [] was not paid for
				  the 7 day waiting period.
If not, was salary continued? [] yes [] no. Was employee
					 paid for the date of injury? [] yes [] no
5. The average weekly wage of the employee at
				  the time of the injury, including overtime and all allowances, was
				  $_____________. This results in a weekly compensation rate of
				  $____________.
6. The employee []
				  has [] has not returned full time to work for _________________________
on ________________________, at an average weekly wage of
					 $__________________.
7.
				  Claimant was released [] with permanent restrictions [] without permanent
				  restrictions. If claimant was released with permanent restrictions and has
				  returned to work for the employer of injury, attach a job description if known
				  to exist.
8. Permanent partial
				  disability compensation will be paid to the injured worker as follows:
____ weeks of compensation at rate of $________ per week
					 for ____% rating to ___________ (body part)
____ weeks of compensation at rate of $________ per week
					 for ____% rating to ___________ (body part)
____ weeks of compensation at rate of $________ per week
					 for ____% rating to ___________ (body part)
Total amount of permanent partial disability compensation
					 is $___________. Date of first payment:______________.
9. State any further matters agreed upon,
				  including disfigurement, loss of teeth, election of temporary partial
				  disability, waiting period or other:
				  ___________________________________________________________________________________.
10. An overpayment is claimed in the amount
				  of $_______________. Overpayment was calculated as
				  follows:_______________________________________________________________________.
If overpayment claimed, a Form 28B, Report of Compensation
					 and Medical Compensation Paid, is attached. [] yes [] no
11. If applicable, the Second Injury Fund
				  Assessment is $ ___________________. A check [] is [] is not included.
The undersigned hereby certify that the material medical
					 and vocational records related to the injury, including any job description
					 known to exist if the employee has permanent restrictions and has returned to
					 work for the employer of injury, have been provided to the employee or the
					 employee's attorney and have been filed with the Industrial Commission for
					 consideration pursuant to
					 G.S.
					 97-82(a) and Rule
					 11 NCAC
					 23A .0501.
_____________________________________________________________________________________________
Name Of Employer Signature Title Date
_____________________________________________________________________________________________
Name Of Carrier/Administrator Signature Direct Phone Number
					 Email Address Title Date
By signing I enter into this agreement and certify that I
					 have read the "Important Notices to Employee" printed on Page 3 of this
					 form.
_____________________________________________________________________________________________
Signature of Employee
Address
Email
					 Address Date
_____________________________________________________________________________________________
Signature of Employee's Attorney Address Email Address
					 Date
[] Check box if no attorney retained.
North Carolina Industrial Commission
The Foregoing Agreement Is Hereby Approved:
_____________________________________________________________________________________________
Claims Examiner Date
_____________________________________________________________________________________________
Attorney's fee approved
IMPORTANT NOTICE TO EMPLOYEE CLAIMING ADDITIONAL WEEKLY
					 CHECKS OR LUMP SUM PAYMENTS
Once your compensation checks have been stopped, if you
					 claim further compensation, you must notify the Industrial Commission in
					 writing within two years from the date of receipt of your last compensation
					 check or your rights to these benefits may be lost.
IMPORTANT NOTICE TO EMPLOYEE INJURED BEFORE JULY 5, 1994
					 CLAIMING ADDITIONAL MEDICAL BENEFITS
If your injury occurred before July 5, 1994, you are
					 entitled to medical compensation as long as it is reasonably necessary, related
					 to your workers' compensation case, and authorized by the carrier or the
					 Industrial Commission.
IMPORTANT NOTICE TO EMPLOYEE INJURED ON OR AFTER JULY 5,
					 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS
If your injury occurred on or after July 5, 1994, your
					 right to future medical compensation will depend on several factors. Your right
					 to payment of future medical compensation will terminate two years after your
					 employer or carrier/administrator last pays any medical compensation or other
					 compensation, whichever occurs last. If you think you will need future medical
					 compensation, you must file an application for additional medical compensation
					 pursuant to
					 G.S.
					 97-25.1 within two years, or your right to
					 these benefits may be lost. An application for additional medical compensation
					 may be made on a Form 18M Employee's Application for Additional Medical
					 Compensation or by written request. In the alternative, an employee may file an
					 application for additional medical compensation by filing a Form 33 Request
					 that Claim be Assigned for Hearing pursuant to
					 11 NCAC
					 23A .0602. All Industrial Commission forms
					 are available at
https://www.ic.nc.gov/forms.html
.
IMPORTANT NOTICE TO EMPLOYER
The employee must be provided a copy of the form when the
					 agreement is signed by the employee. Pursuant to Rule
					 11 NCAC
					 23A .0501, within 20 days after receipt of
					 the agreement executed by the employee, the employer or carrier/administrator
					 must submit the agreement to the Industrial Commission. The employer or
					 carrier/administrator shall file a Form 28B, Report of Compensation and Medical
					 Compensation Paid, within 16 days after the last payment made pursuant to this
					 agreement or be subject to a penalty.
NEED ASSISTANCE?
If you have questions or need help and you do not have an
					 attorney, you may contact the Industrial Commission at (800) 688-8349.
Form 26A
3/2021
Self-Insured Employer or Carrier, File via Electronic
					 Document Filing Portal ("EDFP"):
https://www.ic.nc.gov/docfiling.html
Contact Information:
NCIC- Claims Administration
Telephone: (919) 807-2502
Helpline: (800) 688-8349
Website:
https://www.ic.nc.gov