Form 26A 06/2018 Page 1 of 3 Form 26A ATTORNEYS/CARRIERS/SELF-INSURED EMPLOYERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/ North Carolina Industrial Commission E MPLOYER222S ADMISSION OF EMPLOYEE222S RIGHT TO PERMANENT PARTIAL DISABILITY (G.S. 247 97-31) IC File # Emp. Code# Carrier Code# Carrier File # Employer FEIN The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act ( ) Employee222s Name Employer's Name Telephone Number A ddress Employer222s Address City State Zip City State ZipInsurance Carrier ( ) ( ) Home Telephone Work TelephoneCarrier's Address City State Zip XXX-XX- M F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth 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 Workers222 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. 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:. American LegalNet, Inc. www.FormsWorkFlow.com Form 26A 06/2018 Page 2 of 3 Form 26A ATTORNEYS/CARRIERS/SELF-INSURED EMPLOYERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/ 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 relevant medical and vocational reports related to the injury have been provided to the employee or the employee222s attorney and have been filed with the Industrial Commission for consideration pursuant to G.S. 247 97-82(a) and Rule 11 NCAC 23A .0501. Name of Employer Signature Title Date Name of Carrier/ Administrator Signature Direct phone number Title Date By signing I enter into this agreement and certify that I have read the 223Important Notices to Employee224 printed on page 3 of this form. Signature of Employee Address Date Signature of Employee222s Attorney Address Date Check box if no attorney retained. North Carolina Industrial Commission The FOREGOING AGREEMENT IS HEREBY APPROVED: NCIC Claims Examiner/ Special Deputy/ Other $ ATTORNEY FEE APPROVED American LegalNet, Inc. www.FormsWorkFlow.com Form 26A 06/2018 Page 3 of 3 Form 26A ATTORNEYS/CARRIERS/SELF-INSURED EMPLOYERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/ 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 o r 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, o r your right to these benefits may be lost. To apply you may also use Industrial Commission Form 18M, Employee222s A pplication for Additional Medical Compensation ( G.S. 247 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 23 A .0501, within 20 days after receipt of the agreement executed by the employee, the employer o r 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 Medica l Compensation Paid, within 16 days after the last payment made pursuant to this agreement or be subject 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