Nc workers comp form form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the IC File #, which is essential for tracking your claim. This number will be provided in a return letter.
3. Fill in the Employee’s Name and Address fields accurately, ensuring all details are correct for future correspondence.
4. Complete the Employer's Name and Address sections, including City, State, and Zip Code.
5. Provide your Social Security Number and Date of Birth. Indicate your sex as required.
6. In the Insurance Carrier section, enter the Policy Number and Carrier’s Address along with their contact information.
7. Describe the injury or occupational disease clearly, including specific body parts affected and how it occurred.
8. Indicate your occupation at the time of injury and provide details about medical treatment received, weekly wage, and work hours.
9. If you are unable to sign, ensure that another authorized person signs on your behalf. Retain a copy for yourself and send signed copies to both the Industrial Commission and your employer.

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