FORM 28T 06/2018 PAGE 1 OF 1 FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML CONTACT INFORMATION: NCIC-CLAIMS ADMINISTRATION TELEPHONE: (919) 807-2502 HELPLINE: (800) 688-8349 WEBSITE: HTTP:/ / WWW.IC.NC.GOV FORM 28T North Carolina Industrial Commission IC File # N OTICE OF TERMINATION OF COMPENSATION BY Emp. Code # REASON OF TRIAL RETURN TO WORK Carrier Code # G.S. 247 97-18.1(b) AND G.S. 247 97-32.1 The Use of This Form Is Required Under the Provisions of the Workers' Compensation ActCarrier File # Employer FEIN ( ) 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 Fax Number Important Notice to Employee: Your disability compensation has been stopped because you have returned to work. Y ou are entitled to a trial return to work for a period not to exceed nine months, unless you have been released by an authorized treating physician to unrestricted work, in which case your trial return to work may be limited to 45 days. During your trial return to work, you may be entitled to partial disability compensation if, because of your on-the-job injury, you earn less wages now than before your injury. In order to request that your compensation be reinstated if your trial return to work is unsuccessful, you should complete Form 28U, which may be obtained by calling (800) 688-8349. In addition, you should notify an appropriate person at the company named below in order to request that your compensation be reinstated: NAME OF EMPLOYER OR CARRIER/ADMINISTRATOR A DDRESSTELEPHONE NUMBER When an employee returns to work other than on a trial return to work basis [see I.C. Rule 11 NCAC 23A .0404 A (g)], Form 28 must be used. EMPLOYER: COMPLETE THE FOLLOWING. 1. Date of injury: 2.Date disability began:3. Date temporar y total compensation was/will be terminated:. 4. Date the employee returned/will return to work: at the same or greater wages, than received at the time of injury, or at reduced wages which were/are paid at the rate of $ weekly. If emplo y ee has returned to work at reduced wa g es, is emplo y ee entitled to compensation fo r partial disability pursuant to N.C. Gen. Stat. 247 97-30? yes no If "Yes", submit proper Form, such as Form 26 or Form 62 If not, explain: 5. If different emplo y ment has been verified, name of emplo y er: Address: Telephone:( ) SIGNATURE OF EMPLOYER OR CARRIER /A DMINISTRATORTITLEDATE Employer: The original of this form shall be mailed to the address below, and a copy sent to the employee and the employee's attorney of record, if any. Form 28B must be filed to report the amount and last date compensation and/or medical compensation were paid. American LegalNet, Inc. www.FormsWorkFlow.com