Form 18 - Notice of Accident to Employer and Claim of Employee Representative or Dependent - co currituck nc 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the employee’s name, employer's name, and their respective telephone numbers in the designated fields.
3. Fill in the addresses for both the employee and employer, ensuring that city, state, and zip codes are accurate.
4. Provide the insurance carrier details including policy number and address. Make sure to include all relevant contact information.
5. Complete the section regarding the injury or occupational disease. Include a detailed description of how it occurred, along with the date, time, and location of the incident.
6. Indicate your occupation at the time of injury and provide information about your employer’s business nature.
7. Answer whether medical treatment was received and fill in your weekly wage along with hours worked per day and days worked per week.
8. Sign the form as either an employee, attorney, representative, or dependent. Ensure you enter your contact information and date completed before submission.

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