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Click ‘Get Form’ to open the form 28u in the editor.
Begin by filling in your personal details, including your name, address, and last four digits of your Social Security Number. Ensure accuracy for smooth processing.
In Section A, clearly state your request for total disability compensation to be resumed. Include the dates of your trial return to work and the reason for no longer working.
Obtain a statement from your authorized treating physician confirming your inability to continue working due to injury. This section requires their signature and medical specialty.
If applicable, complete Section B by authorizing your last employer to release employment information related to your trial return to work.
Review all entries for completeness and accuracy before submitting. Send copies as instructed and keep a record of submissions.
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11 N.C. Admin. Code 23A .0404A - TRIAL RETURN TO WORK
Instead, the employer, carrier, or administrator shall return a Form 28U Employees Request that Compensation be Reinstated after Unsuccessful Trial Return toRead more
In applications requiring more than 1 Form C contact, a multicontact relay may be used instead of 2, 3 or 4 of the standard type HG Mercury-Wetted ContactRead more
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