North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter L - INDUSTRIAL COMMISSION FORMS › Section .0100 - WORKERS' COMPENSATION FORMS › Section 23L .0101 - FORM 21 - AGREEMENT FOR COMPENSATION FOR DISABILITY

Current through Register Vol. 39, No. 2, July 15, 2024
(a)
				  The parties to a workers' compensation claim shall use the following Form 21,
				  Agreement for Compensation for Disability, for agreements regarding disability
				  and payment of compensation therefor pursuant to
				  G.S.
				  97-29 and
				  97-30. Additional issues agreed
				  upon by the parties such as payment of compensation for permanent partial
				  disability may also be included on the form. This form is necessary to comply
				  with Rule 11 NCAC 23A .0501, where
				  applicable. The Form 21, Agreement for Compensation for Disability, shall read
				  as follows:
North Carolina Industrial Commission
Agreement for Compensation for Disability
(G.S. 97-82)
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 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 or by __________.
3. The injury by accident or occupational
				  disease resulted in the following injuries: __________
________________________________________________________________________________.
4. The employee [] was/ [] was not
				  paid for the entire day when the injury occurred.
5. The average weekly wage of the employee at
				  the time of the injury, including overtime and all allowances, was $________,
				  subject to verification unless otherwise agreed upon in Item 9 below.
6. Disability resulting from the injury or
				  occupational disease began on ________.
7. The employer and carrier/administrator
				  hereby undertake to pay compensation to the employee at the rate of $________
				  per week beginning ________, and continuing for ________ weeks.
8. The employee [] has / [] has not returned
				  to work for ________________________________ on ________________ , at an
				  average weekly wage of $________.
9. State any further matters agreed upon,
				  including disfigurement, permanent partial, or temporary partial disability:
				  ________________________________________________________________.
10. If applicable, the Second Injury Fund
				  Assessment is $________. Check [] is [] is not attached.
11. The date of this agreement is ________.
				  Date of first payment: ________ Amount: ________.
__________________________________________________________________________________
Name Of Employer Signature Title
__________________________________________________________________________________
Name Of Carrier / Administrator Signature Title
By signing I enter into this agreement and certify that I
					 have read the "Important Notices to Employee" printed on Page 2 of this
					 form.
__________________________________________________________________________________
Signature of Employee Address
__________________________________________________________________________________
Signature of Employee's Attorney Address
North Carolina Industrial Commission
The Foregoing Agreement Is Hereby Approved:
___________________________________________
Claims Examiner Date
___________________________________________
Attorney's Fee Approved
[] Check Box If No Attorney Retained.
[] Check Box If Employee Is In Managed Care.
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.
					 97-25.1within 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 formwhen 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 21
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