01. Edit your claim affirmation form online
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To view the List Click here for the Claim form and Instructions 2026
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02. Sign it in a few clicks
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How to use or fill out to view the List Click here for the Claim form and Instructions
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the Claim Affirmation Form. Ensure you type or print legibly in blue or black ink, as illegible claims will be returned.
- If your claim exceeds $1,000, sign the form and have it notarized. Review all instructions carefully and prepare copies of required documents such as your driver’s license.
- Each claimant must complete a separate Claim Affirmation Form. Gather all necessary documentation based on your claim type—original owner, deceased owner, or business.
- Submit your completed form along with all required materials either by mailing them to the specified address or emailing them in PDF format.
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claim affirmation form pdf
Claim Instructions and Form Page s Claim Instructions Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other
All current forms used by the NC Industrial Commission can be found here. For Claimants Click Here for a list of forms used primarily by Claimants for Workers