Form 22 2026

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The document is a form from the North Carolina Industrial Commission, titled 'Statement of Days Worked and Earnings of Injured Employee.' It is required under the Workers' Compensation Act to report an injured employee's workdays and earnings prior to their injury. The form includes sections for employer and employee information, earnings details for each month, and instructions for completion and filing. It emphasizes the importance of accuracy in reporting to avoid penalties.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Employer FEIN, Employee’s Name, and Employer's Name in the designated fields. Ensure accuracy as this information is crucial for processing.
Fill in the Address and Telephone Number for both the employer and employee. This helps maintain clear communication regarding the claim.
In the earnings section, mark an 'X' in the appropriate squares to indicate days worked and paid leave. For any unpaid days, leave those squares blank.
Record total earnings for each month in the corresponding columns. If there were changes in job or pay rate during this period, note these changes clearly.
Finally, ensure that all required signatures are completed before submitting your form electronically through our platform.

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