Form 25r 2026

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The document is a form used by the North Carolina Industrial Commission for evaluating permanent impairment related to work-related injuries under the Workers' Compensation Act. It includes sections for employee and employer information, details about the injury, percentage of impairment for various body parts, and requirements for physician signatures. Additionally, it outlines rules for compensation calculations regarding amputations and specifies that a copy must be provided to the employee or their attorney.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the IC File Number, Employee Code, and Carrier Code at the top of the form. These identifiers are crucial for tracking your claim.
Fill in the Employer's FEIN and name, followed by the employee’s name and address. Ensure all details are accurate to avoid processing delays.
In the section regarding the employee's work-related injury, indicate the percentage of impairment for each body part affected. If applicable, describe any amputations on the reverse side.
Complete the physician's signature section, including their printed name and Federal Tax ID Number. This validates your submission.
Finally, review all entries for accuracy before submitting. Attach any necessary documents such as audiograms or calculations of hearing loss as required.

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