FORM 21 06/2018 PAGE 1 OF 2 FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML FORM 21 North Carolina Industrial Commission IC File # A GREEMENT FOR COMPENSATION FOR DISABILITY Emp. Code # (G.S. 247 97-82) Carrier Code # Carrier File # The Use of This Form Is Required Under the Provisions of the Workers' Compensation ActEmployer FEIN ( ) Employee222s Name Employer's Name Telephone Number A ddress Employer222s Address City State Zip City State Zip Insurance Carrier ( ) ( ) Home Telephone Work Telephone Carrier's Address City State Zip XXX-XX- M F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth Carrier's Telephone Number Fax Number WE, THE UNDERSIGNED, DO HEREBY A GREE A ND STIPULATE A S FOLLOWS: 1. A ll 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 line 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 fo r weeks.8. The employee has / has not returned to work fo r 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 223Important Notices to Employee224 printed on Page 2 of this form. Signature of Employee Address Signature of Employee222s Attorney Address NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING AGREEMENT IS HEREBY APPROVED: CHECK BOX IF NO ATTORNEY RETAINED. CLAIMS EXAMINER DATE CHECK BOX IF EMPLOYEE IS IN MANAGED CARE. A TTORNEY222S FEE A PPROVED American LegalNet, Inc. www.FormsWorkFlow.com FORM 21 06/2018 PAGE 2 OF 2 FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML FORM 21 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 ma y 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 apply to the Industrial Commission in writing within two years, or your right to these benefits may be lost. To apply you may also use Industrial Commission Form 18M, Employee222s Application for Additional Medical Compensation ( G.S. 97-25.1 ) , available at http://www.ic.nc. g ov/forms.html. IMPORTANT NOTICE TO EMPLOYER The employee must be provided a copy 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, or show cause for not submitting the agreement. The employer or carrier/administrator shall file a Form 28B, Report of Compensation and Medical Compensation Paid, within 16 da y s after the last pa y ment made pursuant to this a g reement or be sub j ect to a penalt y . 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. American LegalNet, Inc. www.FormsWorkFlow.com