The North Carolina 28 form is a document used to report an employee's return to work after a period of disability due to a work-related injury. This form is essential for employers and insurance carriers to communicate the status of an employee's work capabilities under the Workers' Compensation Act. Proper completion and submission of the form ensure that all parties are informed and that any necessary adjustments to compensation can be made.
The North Carolina 28 form plays a crucial role in the workers' compensation process, specifically addressing situations where an employee returns to work after an injury. This form is required by the North Carolina Industrial Commission and serves to notify relevant parties about the employee's return status. It captures essential information such as the employee's name, Social Security number, and details about their employer and insurance carrier. One significant aspect of the form is its distinction between a regular return to work and a trial return to work. If an employee is returning on a trial basis, a different form—Form 28T—must be used instead. This distinction is vital as it impacts the employee's eligibility for disability compensation. The form also outlines the responsibilities of the employer or insurance carrier, requiring them to provide specific dates related to the injury and the return to work. Furthermore, if the employee is returning with reduced wages or to a different employer, additional details must be included. Completing the North Carolina 28 form accurately ensures that all parties are informed and helps facilitate the proper management of the employee's compensation benefits.
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NORTH CAROLINA INDUSTRIAL COMMISSION
IC File #
RETURN TO WORK REPORT
Emp. Code #
Carrier Code # Carrier File #
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
Employer FEIN
Employee’s Name
Address
City
State
Zip
(
)
Home Telephone
Work Telephone
M F
/
Social Security Number
Sex
Date of Birth
Employer's Name
Telephone Number
Employer’s Address
Insurance Carrier
Carrier's Address
Carrier's Telephone Number
Fax Number
Employer: The use of this form is not appropriate when an employee has returned to work on a trial return to work basis pursuant to N.C. Gen. Stat. § 97-32.1, in which case Form 28T must be used. By using this form you are stating that this case is not a trial return to work and that one of the exclusions contained in NCIC Rule 404A(7) applies.
Important Notice To Employee: Your disability compensation has been stopped because you have returned to work. You are entitled to a trial return to work for a period not to exceed nine months, unless you have been released by an authorized treating physician to unrestricted work, in which case your trial return to work may be limited to 45 days. During your trial return to work, you may be entitled to partial disability compensation if, because of your on-the-job injury, you earn less wages now than before your injury. If your trial return to work is unsuccessful, you should complete form 28U in order to request that your compensation be reinstated.
THE EMPLOYER OR CARRIER/ADMINISTRATOR MUST COMPLETE THE FOLLOWING
WHEN EMPLOYEE RETURNS TO WORK OTHER THAN ON A TRIAL RETURN TO WORK BASIS.
SECTION A. COMPLETE THE FOLLOWING:
1.Date of injury:
2.Date disability began:
3.Date returned to work:
SECTION B. COMPLETE IF EMPLOYEE RETURNED TO WORK FOR REDUCED WAGES:
Employee is being paid at the rate of $
weekly.
SECTION C. COMPLETE IF EMPLOYEE RETURNED TO WORK FOR A DIFFERENT EMPLOYER:
1.Name of that employer:
2.Address:
3.Telephone:
SIGNATURE OF EMPLOYER OR CARRIER/ADMINISTRATOR
TITLE
DATE
Employer: The original of this form shall be sent to the address below, and a copy sent to the employee and the employee's attorney of record, if any. A Form 28B must be filed to report the amount and last date compensation and/or medical compensation were paid.
MAIL TO: NCIC - CLAIMS SECTION
4335 MAIL SERVICE CENTER
FORM 28
RALEIGH, NC 27699-4335
2/01
MAIN TELEPHONE: (919) 807-2500
PAGE 1 OF 1
HELPLINE: (800) 688-8349
WEBSITE: HTTP://WWW.IC.NC.GOV/
Filling out and using the North Carolina 28 form is an essential process for employers and employees involved in workers' compensation claims. Here are key takeaways to consider:
Understanding these aspects can help ensure compliance with the Workers' Compensation Act and protect the rights of all parties involved.