Form 19 2008-2025

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The document is an Employer's Report of Employee's Injury or Occupational Disease (Form 19) required by the North Carolina Industrial Commission. It outlines the responsibilities of both employers and employees regarding reporting workplace injuries and filing claims for workers' compensation. Employers must submit this form to their insurance carrier within five days of learning about an injury, while employees are instructed to complete a separate Form 18 to officially file a claim within two years of the incident.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the IC File # and Employer Code # at the top of the form. These are essential for identifying the injury report.
Fill in the employer's details, including name, address, and FEIN. Ensure all required fields marked with an asterisk (*) are completed.
Provide information about the employee, including their name, Social Security Number, date of birth, and contact details.
Detail the incident by specifying the location, date, time of injury, and nature of business. Include a description of how the injury occurred.
Complete sections regarding wages and employment duration. This includes average weekly wages and any additional benefits provided.
Review all entries for accuracy before submitting. Once finalized, transmit the form through your insurance carrier as required by law.

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What is the purpose of Form 19?

EPF Form 19 is used to claim your Employee Provident Fund (EPF) balance as a final settlement after leaving employment. An EPFO member can submit Form 19 in the following situations: Retirement after docHubing the age of 55 years. Retirement due to physical or mental incapacity to work.

Is form 19 for full PF withdrawal?

Form 19 must be used when you wish to withdraw EPF funds in the form of the final settlement. An EPFO member can use Form 19 under the following circumstances: Retirement on attaining 55 years of age or attained 55 years of age. Retirement on account of inability to work due to mental/ bodily infirmity.

What is the process to submit Form 19?

This Form 19 must be transmitted to the Commission through your insurance carrier/claims administrator, and is required by law to be filed within 5 days after knowledge of accident. Employer must also give employee a blank Form 18.