FORM 19 10/2017 PAGE 1 OF 2 FOR IC USE ONLY RESEARCHER: CC: EC: DATA ENTRY: FORM 19 SELF-INSURED EMPLOYER OR CARRIER, FILE AS FROI VIA EDI:HTTP://WWW.IC.NC.GOV/EDIFORM19.HTML UNINSURED EMPLOYERS OR LUNG DISEASE CLAIMS: E-MAIL TO: FORMS@IC.NC.GOV OR MAIL TO: NCIC - CLAIMS SECTION,1235 MAIL SERVICE CENTER, RALEIGH, NC 27699-1235 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV / North Carolina Industrial Commission IC File # E MPLOYER222S REPORT OF EMPLOYEE222S INJURY OR Emp. FEIN OCCUPATIONAL DISEASE TO THE INDUSTRIAL COMMISSION CarrierFEIN To the Employer: A copy of this Form 19 accompanied by a blank Form 18 must be given to the employee. It does not satisfy the employee222s obligation to file a claim. The filing of this report is required by law. This form MUST be transmitted to the Industrial Commission through your Insurance Carrier. To the Employee: This Form 19 is not your claim for workers222 compensation benefits. To make a claim, you must complete and sign the enclosed Form 18 and mail it to Claims Administration, N.C. Industrial Commission, 1235 Mail Service Center, Raleigh, NC 27699-1235 within two years of the date of your injury or last payment of medical compensation. For occupational diseases, the claim must be filed within two years of the date of disability or the date your doctor told you that you have a work-related disease, whichever is later. The Use of This Form Is Required Under the Provisions of the Workers' Compensation ActCarrier File # The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence. () -Employee222s Name Employer222s Name Telephone Number A ddress Employer222s Address City State Zip City State ZipInsurance Carrier Policy Number ( ) - ( ) - Home Telephone Work Telephone Carrier222s Address City State Zip - - M F / / () -( ) -Social Security Number Sex Date of Birth Carrier222s Telephone Number Fax Number Employer 1. Give nature of employer222s business 2. Location of plant where in j ur y occurred Time Count y DepartmentState if emplo y er222s premises And 3. Date of injury / / 4. Day of week Hour of day : A.M. P.M. Place 5. Was employee paid for entire day 6.Date disability began / / A.M. P.M. 7. Date you or the supervisor first knew of injury / / 8. Name of supervisor 9. Occupation when injured Person 10. (a) Time employed by you (b) Wages per hour $ Injured 11. (a) No. hours worked per day(b) Wages per day $(c) No. of days w orked per week (d) Avg. weekly wages w/ overtime$ (e) If board, lodging, fuel or other advantages were furnished in addition to wa g es, estimated value per da y , week or month. $ per 12. Describe fully how injury occurred and what employee was doing when injured: Cause And Nature Of Injury (Statement made without prejudice and without vouching for correctness of information) 13. List all injuries and specify body part involved (e.g. right hand or left hand): 14. Date & hour returned to work / / at :.M.15.If so, at what wages $ per 16. At what occupation 17.Emplo y ee222s salar y continued in full? 18. Was emplo y ee treated b y a ph y sician Fatal Cases 19. Has in j ured emplo y ee died 20.If so, g ive date of death ( Submit Form 29 ) / / Employer name Date Completed / / Signed by Official Title OSHA 301 Information: Case Number from Log: Date Hired: / / Time Employee began work on date of incident: : A.M. P.M.If off-site medical treatment provided, answer entire next line. Name of facility: Address: Street/City/Zip/Telephone ER visit? Yes No Overnight stay? Yes No Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. American LegalNet, Inc. www.FormsWorkFlow.com FORM 19 10/2017 PAGE 2 OF 2 FORM 19 SELF-INSURED EMPLOYER OR CARRIER, FILE AS FROI VIA EDI:HTTP://WWW.IC.NC.GOV/EDIFORM19.HTML UNINSURED EMPLOYERS OR LUNG DISEASE CLAIMS: E-MAIL TO: FORMS@IC.NC.GOV OR MAIL TO: NCIC - CLAIMS SECTION, 1235 MAIL SERVICE CENTER, RALEIGH, NC 27699-1235 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV / IMPORTANT INFORMATION FOR EMPLOYER Employer must furnish a copy of this form, as completed, to the employee or the employee222s representative when submittedto the Insurance Carrier or Claims Administrator for transmission to the Commission. Every question must be answered. ThisForm 19 must be transmitted to the Commission through your insurance carrier/claims administrator, and is required by lawto be filed within 5 da y s after knowled g e of accident. Emplo y er must also g ive emplo y ee a blank Form 18. IMPORTANT INFORMATION FOR EMPLOYEE Reporting an Injury If you do not agree with the description or time of the accident given on this form, you should make a written report of injury to the employer within thirty (30) days of the injury. Making A Claim To be sure you have filed a claim, complete a Form 18, Notice of Accident, within two years of the date of the injury and send a copy to the Industrial Commission and to your employer. The employer is required by law to file this Form 19, but the filing of the Form 19 does not satisfy the employee222s obligation to file a claim. The employee must file a Form 18 even though the employer may be paying compensation without an agreement, or the Commission may have opened a file on this claim. A claim may also be made by a letter describing the date and nature of the injury or occupational disease. This letter must be signed and sent to the Industrial Commission and to your employer. FOR ASSISTANCE OR TO OBTAIN A FORM 18 FROM THE INDUSTRIAL COMMISSION, YOU MAY CALL (800) 688-8349 USE YOUR I.C. FILE NUMBER (IF KNOWN) OR SOCIAL SECURITY NUMBER ON ALL FUTURE CORRESPONDENCE WITH THE COMMISSION [SPANISH TRANSLATION] INFORMACI323N IMPORTANTE PARA LOS EMPLEADOS Reporte de una Lesi363n (Reporting an Injury) Si usted no est341 de acuerdo con la descripci363n o la hora del accidente que aparece en el formulario, debe hacer un reporte de la lesi363n por escrito y d341rselo a su empleador dentro de un per355odo de treinta (30) d355as a partir de la fecha de la lesi363n. C363mo Presentar una Reclamaci363n (Making a Claim) Para ceriorarse de que ha presentado una reclamaci363n, complete el Formulario 18 Notificaci363n de Accidente dentro de un per355odo de dos a361os a partir de la fecha de la lesi363n y env355e una copia a la Comisi363n Industrial y una copia a su empleador. Por ley, el empleador debe presentar el Formulario 19, sin embargo, el presentar el Formulario 19 no cumple con la obligaci363n que tiene el empleado de presentar una reclamaci363n. El empleado debe presentar el Formulario 18 aunque el empleador est351 pagando compensaci363n sin tener un acuerdo o si la Comisi363n ha creado un expediente con respecto a esta reclamaci363n. Tambi351n se puede presentar una reclamaci363n por medio de una carta explicando la fecha y la naturaleza de la lesi363n o la enfermedad ocupacional. Esta carta se debe firmar y enviar a la Comisi363n Industrial as355 como al empleador. PARA RECIBIR ASISTENCIA O PARA OBTENER EL FORMULARIO 18 DE LA COMISI323N INDUSTRIAL, USTED PUEDE HABLAR AL (800) 688-8349 EN TODA LA CORRESPONDENCIA QUE ENV315E A LA COMISI323N INDUSTRIAL POR FAVOR ESCRIBA EL N332MERO DE CASO DESIGNADO POR LA COMISI323N [I.C. FILE NUMBER] (SI LO SABE) O SU N332MERO DE SEGURO SOCIAL. American LegalNet, Inc. www.FormsWorkFlow.com