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Statement Of Days Worked And Earnings Of Injured Employee Form. This is a North Carolina form and can be use in Workers Comp.
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Tags: Statement Of Days Worked And Earnings Of Injured Employee, 22, North Carolina Workers Comp,
North Carolina Industrial Commission
IC File #
STATEMENT OF DAYS WORKED AND EARNINGS OF
INJURED EMPLOYEE
Emp. Code #
Carrier Code #
Carrier File #
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
Employer FEIN
(
Employee’s Name
Address
)
-
Employer's Name
Telephone Number
Employer’s Address
,
,
)
State
-
(
Home Telephone
/
State
City
State
Zip
,
City
(
,
City
Zip
)
-
Work Telephone
/
M
Social Security Number
F
/
Sex
Date of Injury:
/
2
3
/
,
(
Date of Birth
,
Carrier's Address
)
-
(
Carrier's Telephone Number
)
Zip
Fax Number
/
Year:
200
Insurance Carrier
1
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Amount
Earned
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
Total
Was this employee given free rent, lodging, or board or other allowances made in lieu of wages?
If so, state weekly value thereof: $
.
.
SELF-INSURED EMPLOYER OR CARRIER MAIL TO:
FORM 22
10/2006
PAGE 1 OF 2
FORM 22
NCIC - CLAIMS SECTION
4335 MAIL SERVICE CENTER
RALEIGH, NC 27699-4335
TELEPHONE: (919) 807-2502
HELPLINE: (800) 688-8349
WEBSITE: HTTP://WWW.IC.NC.GOV/
American LegalNet, Inc.
www.FormsWorkflow.com
,
The undersigned employer of
(Name of Employee)
who alleges an injury on the
of
,
(Day)
200
(Month)
(Year)
while in the employment of the undersigned, does hereby certify that the above is a true and correct
statement of days worked and earnings of this employee during the 52 weeks immediately preceding
the injury (or during the above weeks and parts thereof, if employed for less than 52 weeks) and while
engaged in the occupation in which the employee was allegedly injured.
Employer
By
Authorized Signature
/
/200
Date Signed
To Employer: Making a false statement for the purpose of denying workers’
compensation benefits may result in civil or criminal penalties.
INSTRUCTIONS
This form must be completed and filed with the Commission in all
cases resulting in death unless maximum compensation rate is
stipulated. It must also be filed in any other case if there is a
disagreement about earnings or if the Commission requests it.
In preparing this form, place an X in the proper squares to indicate
days paid in full. Days the employee is on paid vacation leave and/or paid
sick leave should be marked with an X. Leave blank squares to indicate
days not paid in full for any reason. Total earnings for each pay period
should be placed in the proper column. If the employee's job or pay rate
was changed during the reported period, this should be noted, with an
indication as to the nature of the change.
The employer code number and the carrier code number, if any, must
be inserted in the proper place at the upper right-hand corner of the form.
SELF-INSURED EMPLOYER OR CARRIER MAIL TO:
FORM 22
10/2006
PAGE 2 OF 2
FORM 22
NCIC - CLAIMS SECTION
4335 MAIL SERVICE CENTER
RALEIGH, NC 27699-4335
TELEPHONE: (919) 807-2502
HELPLINE: (800) 688-8349
WEBSITE: HTTP://WWW.IC.NC.GOV/
American LegalNet, Inc.
www.FormsWorkflow.com
