The North Carolina 90 form is a report used to document earnings for individuals receiving workers' compensation benefits. This form is essential for both employees and employers, as it helps verify ongoing eligibility for benefits under the Workers' Compensation Act. Completing and submitting this form accurately and on time is crucial to avoid any interruptions in benefits.
The North Carolina 90 form is a critical document used in the workers' compensation process, specifically designed to report an employee's earnings while receiving benefits. This form is mandated by the North Carolina Workers' Compensation Act, ensuring that both employers and insurance carriers can verify an employee's ongoing eligibility for benefits. Employees must provide personal details, including their name, address, and Social Security number, along with information about their earnings during a specified time period. It is essential for employees to understand that they must report any earnings from self-employment or other jobs, even if those earnings seem insignificant or the business lost money. The form also includes a section where employees affirm that they have not concealed any material facts regarding their compensation status. Timeliness is crucial; employees are required to return the completed form within 15 days of receipt to avoid suspension of benefits. Failing to comply can lead to serious consequences, including civil and criminal penalties. This form not only serves as a means of communication between employees and insurers but also plays a vital role in maintaining the integrity of the workers' compensation system in North Carolina.
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NORTH CAROLINA INDUSTRIAL COMMISSION
IC File #
REPORT OF EARNINGS
Emp. Code #
Carrier Code #
Carrier File #
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Employer FEIN
(EMPLOYER/INSURANCE CARRIER TO COMPLETE THIS SECTION)
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
To Employees: The Employer/Insurance Carrier periodically needs to verify your continuing eligibility for workers' compensation benefits and to update their records. You are required to complete Page 2 of this Report of Earnings and return it to the insurer or employer address provided on page 2 of this form within 15 days after receipt of this form, even if you have no earnings.
**YOUR WORKERS' COMPENSATION BENEFITS MAY BE SUSPENDED IF YOU FAIL
TO COMPLETE THIS REPORT IN A TIMELY MANNER.**
NOTICE TO EMPLOYEES RECEIVING WORKERS' COMPENSATION
When you are receiving weekly workers' compensation benefits, YOU MUST REPORT ANY EARNINGS YOU RECEIVE TO THE INSURANCE CARRIER (OR EMPLOYER IF THE EMPLOYER IS SELF-INSURED) THAT IS PAYING YOU THE BENEFITS. "Earnings" include any cash, wages or salary received from self-employment or from any employment other than the employment where you were injured. Earnings also include commissions, bonuses, and the cash value for all payments received in any form other than cash (e.g., a building custodian receiving a rent-free apartment). Commissions, bonuses, etc., earned before your disability do not constitute earnings that must be reported.
You must report any work in any business, even if the business lost money or if profits or income were reinvested or paid to others.
Your endorsement on a benefit check or deposit of the check into an account is your statement that you are entitled to receive workers' compensation benefits. Your signature on a benefit check is a further affirmation that you have made no false claims or statements or concealed any material fact regarding your right to receive workers' compensation benefits.
MAKING FALSE STATEMENTS FOR THE PURPOSE OF OBTAINING WORKERS' COMPENSATION BENEFITS
MAY RESULT IN CIVIL AND CRIMINAL PENALTIES.
TIME PERIOD COVERED BY THIS REPORT: ___________________ to _____________________
(Employer/Insurance Carrier must complete)
FORM 90 2/01
PAGE 1 OF 2
FORM 90
4340 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-4340
MAIN TELEPHONE: (919) 807-2500
HELPLINE: (800) 688-8349
WEBSITE: HTTP://WWW.IC.NC.GOV/
EMPLOYEE: COMPLETE SECTION BELOW
(1) Did you receive earnings from work during the time period
indicated on Page 1?
YES
NO
(2) Did you work for a business or any person during that time
period?
(3)If you answered NO to both questions 1 and 2, sign and return the form to the insurance carrier or to the individual identified by the insurance carrier or employer listed below.
(4)If you answer YES to either question, complete item 5 below, sign and return the form to the insurance carrier or to the individual identified by the insurance carrier or employer listed below. For the purposes of this statement, “Gross Earnings” include all pre-tax earnings, bonuses, commissions, and/or the cash value of any payment received in any form other than cash.
(5)1st Employer or Business Name (include self-employment):
Location:
Dates worked:
Gross Earnings:
Next Employer or Business Name (include self-employment):
Attach additional page(s) if necessary.
Employee Signature:
Date:
.
(Required)
NOTICE TO EMPLOYEE:
1.Failure to report earnings as defined herein may subject you to criminal prosecution and civil liability including the suspension or forfeiture of your benefits. This form must be signed and returned to the insurance carrier listed below even if you have no earnings.
2.If the Commission suspends benefits for failure to complete and return a Form 90 Report of Earnings, the self-insured employer, insurance carrier or third party administrator shall immediately reinstate benefits to the employee with back payment as soon as the Report of Earnings is submitted by the employee.
3.If benefits are not immediately reinstated, the employee should submit a written request for an Order from the Executive Secretary instructing the employer or insurance carrier to reinstate benefits. An application for reinstatement of benefits should be addressed to North Carolina Industrial Commission, Office of the Executive Secretary, 4333 Mail Service Center, Raleigh, NC 27699-4333.
Insurance carrier or Employer must list the name and address below of the person to whom this form must be returned and mail this form to the employee by certified mail return receipt requested, and include a self-addressed stamped envelope for the return of the Form.
Name:
Address:
NOTICE TO INSURER OR EMPLOYER:
Any person who willfully makes a false statement or representation of a material fact for the purpose of denying or assisting another in denying any benefit or payment under the Workers’ Compensation Act shall be guilty of a Class 1 misdemeanor if the amount at issue is less than $1000. Violation is a Class H felony if the amount at issue exceeds $1000. Any person who threatens an employee with criminal prosecution under the provisions of the Act for the purpose of coercing or attempting to coerce an employee into agreeing to compensation under the Act shall be guilty of a Class H felony.
PAGE 2 OF 2
Filling out and using the North Carolina 90 form is a crucial process for both employees and employers involved in workers' compensation claims. Here are some key takeaways to keep in mind:
Understanding these points can help ensure compliance with the requirements of the North Carolina 90 form, ultimately supporting a smoother claims process for all parties involved.