Ncic form 28u 2002-2026

1. Click ‘Get Form’ to open the ncic form 28u 2002 in the editor.
2. Begin by filling in your personal information, including your name, address, and social security number. Ensure accuracy as this information is crucial for processing your request.
3. 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.
4. Obtain a statement from your authorized treating physician certifying that you are unable to continue working due to your injury. This should include their signature and medical specialty.
5. If applicable, complete Section B by authorizing your last employer to release employment information regarding your trial return to work. Sign and date this section.
6. Once completed, send a copy of the form to both your employer and the carrier/administrator. Mail the original document to the Industrial Commission at the provided address.

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