Fill in Your 19 North Carolina Template Open Your Form Online

Fill in Your 19 North Carolina Template

The North Carolina Form 19 is the Employer’s Report of an Employee's Injury or Occupational Disease, which must be submitted to the Industrial Commission. Employers are required by law to provide this form to the injured employee along with a blank Form 18, which is necessary for filing a workers’ compensation claim. Timely submission of Form 19 is crucial, as it must be filed within five days of the employer's knowledge of the incident.

The 19 North Carolina form, officially known as the Employer’s Report of Employee's Injury or Occupational Disease, plays a critical role in the workers' compensation process in North Carolina. This form must be completed by employers and submitted to the Industrial Commission through their insurance carrier within five days of learning about an employee's injury or occupational disease. While the employer is responsible for filing this form, it is essential to note that it does not serve as the employee's claim for benefits. Employees must complete a separate Form 18 to initiate their claim for workers' compensation. The 19 form requires detailed information, including the nature of the employer's business, the location and circumstances of the injury, and specific details about the employee's occupation and wages. Additionally, it includes sections for documenting the timeline of the injury, medical treatment, and any potential fatal outcomes. Importantly, both employers and employees are obligated to understand their responsibilities under the Workers’ Compensation Act, ensuring that claims are filed accurately and timely. This form is a foundational document in the claims process, establishing the necessary details for both the employer and the employee to navigate the complexities of workers' compensation effectively.

Misconceptions

Misconceptions about the North Carolina Form 19 can lead to confusion for both employers and employees. Here are eight common misunderstandings:

  • Form 19 is a claim for benefits. Many believe that submitting Form 19 constitutes a claim for workers’ compensation benefits. In reality, it is merely a report of the injury.
  • Employers do not need to provide a copy to the employee. Some think that employers can skip giving a copy of Form 19 to the injured employee. However, this is required by law.
  • Submitting Form 19 is sufficient for filing a claim. There is a misconception that submitting Form 19 alone fulfills the employee's obligation to file a claim. Employees must also complete and submit Form 18.
  • Form 19 must be filed immediately by the employee. Some individuals believe that employees must file Form 19 themselves. In fact, it is the employer's responsibility to file this form within five days of knowledge of the injury.
  • Form 19 does not require detailed information. Some assume that the form can be filled out with minimal information. All questions on the form must be answered thoroughly.
  • There is no time limit for filing a claim. Many people think there is no deadline for filing a claim after an injury. In North Carolina, claims must be filed within two years of the injury or last payment of medical compensation.
  • Occupational disease claims are treated the same as injury claims. Some believe that the process for claiming occupational diseases is identical to that of physical injuries. The timelines for filing are different and can depend on when the employee was informed of the disease.
  • Employers can choose not to file Form 19. There is a misconception that employers can opt out of filing Form 19. Filing this form is a legal requirement for employers when an injury occurs.

Understanding these misconceptions can help ensure that both employers and employees navigate the workers' compensation process more effectively.

Similar forms

  • Form 18 - Notice of Accident: This form is essential for employees to formally file a claim for workers’ compensation benefits. Similar to Form 19, it is part of the process of reporting workplace injuries, but it specifically serves as the employee's claim, while Form 19 is the employer's report.
  • Transfer-on-Death Deed: A Kentucky Transfer-on-Death Deed is a legal document that allows property owners to transfer their real estate to beneficiaries upon their death without going through probate. This form simplifies the transfer process, ensuring that loved ones receive the property directly. Understanding how to properly use this deed can help individuals manage their estate planning effectively, particularly through the Transfer-on-Death Deed form.
  • Form 29 - Report of Fatality: In cases where an employee dies due to a work-related incident, Form 29 must be submitted. Like Form 19, it is a formal report that must be filed with the Industrial Commission, but it specifically addresses fatal incidents rather than general injuries.
  • Form 30 - Application for Hearing: This form is used when there is a dispute regarding a workers' compensation claim. While Form 19 is focused on reporting an injury, Form 30 is a step taken by employees when they seek a hearing to resolve issues with their claims.
  • OSHA 301 - Injury and Illness Incident Report: This document is used to report workplace injuries and illnesses, similar to Form 19. However, OSHA 301 is primarily focused on compliance with safety regulations, whereas Form 19 is specifically for workers’ compensation reporting.
  • Form 21 - Agreement for Compensation: This form is used to formalize an agreement between the employer and employee regarding compensation for a work-related injury. Like Form 19, it is part of the workers’ compensation process, but it deals with the agreement rather than the reporting of the injury.

Steps to Writing 19 North Carolina

Filling out the Form 19 is an important step for employers reporting an employee's injury or occupational disease. After completing the form, it must be submitted to the Industrial Commission through the insurance carrier. Ensure all sections are filled out accurately to comply with legal requirements.

  1. Obtain the Form 19 from your insurance carrier or the Industrial Commission website.
  2. Enter the I.C. File #, which will be provided by the Industrial Commission.
  3. Fill in the Employer Code # and Carrier Code #.
  4. Provide the Employer FEIN (Federal Employer Identification Number).
  5. Complete the employee's details: name, address, home telephone number, and Social Security Number.
  6. Enter the employer's name and address, including city, state, and zip code.
  7. Fill in the insurance carrier's details, including city, state, zip code, policy number, and telephone number.
  8. Indicate the employee's work telephone number and the carrier's address.
  9. Provide the employee's sex and date of birth.
  10. List the nature of the employer's business.
  11. Specify the location of the plant where the injury occurred.
  12. Record the date and time of the injury, including the day of the week.
  13. Indicate if the employee was paid for the entire day.
  14. Enter the date when the disability began.
  15. Provide the date you or the supervisor first knew of the injury.
  16. Enter the name of the supervisor.
  17. Specify the employee's occupation at the time of the injury.
  18. Fill in the duration of employment with the company.
  19. Provide details about hours worked per day and average weekly wages, including overtime.
  20. Describe how the injury occurred and what the employee was doing at the time.
  21. List all injuries and specify the body parts involved.
  22. Record the date and hour the employee returned to work.
  23. Indicate the wages at which the employee returned to work.
  24. State if the employee's salary continued in full.
  25. Specify the occupation the employee held upon return.
  26. If applicable, indicate if the employee was treated by a physician.
  27. For fatal cases, provide the date of death and submit Form 29.
  28. Complete the OSHA 301 information, including case number and facility name.
  29. Sign the form and ensure it is dated.

Once completed, make sure to provide a copy of this form to the employee or their representative. Submit the form to the insurance carrier for transmission to the Industrial Commission within the required timeframe. Remember, this form does not replace the employee's obligation to file a claim using Form 18.

19 North Carolina Example

Documents used along the form

When dealing with workplace injuries in North Carolina, several forms and documents are crucial for both employers and employees. Each of these documents serves a specific purpose in ensuring that the claims process is handled efficiently and within the legal framework. Below are some key forms that are commonly used alongside the North Carolina Form 19.

  • Form 18: Notice of Accident - This form is essential for employees to officially file a claim for workers' compensation benefits. It must be completed and sent to the Industrial Commission within two years of the injury or the last medical compensation payment.
  • Form 29: Report of Fatality - In cases where an employee dies due to a work-related incident, this form must be submitted. It provides necessary details regarding the fatality and is required for the processing of death benefits.
  • Form 30: Application for Hearing - If there are disputes regarding a claim, this form allows an employee to request a hearing before the Industrial Commission. It is a critical step for resolving issues related to benefits or compensation.
  • Form 21: Agreement for Compensation - This document is used when both the employer and employee agree on the amount of compensation to be paid. It formalizes the agreement and is necessary for the timely processing of payments.
  • Operating Agreement: For those establishing an LLC in Georgia, ensure you have your comprehensive Operating Agreement setup to outline your business structure and member responsibilities.
  • Form 26: Application for Approval of a Compromise Settlement - If a settlement is reached outside of the standard claims process, this form is required to obtain approval from the Industrial Commission. It ensures that the settlement is fair and complies with legal standards.
  • OSHA 301: Injury and Illness Incident Report - This form is used to document work-related injuries and illnesses. It is part of the employer's record-keeping requirements and helps in analyzing workplace safety and health trends.

Understanding these forms and their purposes is vital for both employers and employees navigating the workers' compensation system. Timely and accurate completion of these documents can significantly affect the outcome of a claim, ensuring that injured workers receive the benefits they deserve while maintaining compliance with state regulations.