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North Carolina Industrial Commission IC File EMPLOYER S REPORT OF EMPLOYEE S INJURY OR OCCUPATIONAL DISEASE TO THE INDUSTRIAL COMMISSION Emp. Code Carrier Code To the Employer A copy of this Form 19 accompanied by a blank Form 18 must be given to the employee. Date Hired Time Employee began work on date of incident Address Street/City/Zip/Telephone SELF-INSURED EMPLOYER OR CARRIER MAIL TO FORM 19 8/1/08 PAGE 1 OF 2 NCIC - CLAIMS ADMINISTRATION FOR IC USE ONLY RESEARCHER CC DATA ENTRY 4335 MAIL ...

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