Blank North Carolina 28 PDF Form

How to Use North Carolina 28

Filling out the North Carolina 28 form is a straightforward process. This form is essential for reporting an employee's return to work after a disability. Make sure to have all necessary information at hand to complete it accurately. Follow the steps below to ensure you fill out the form correctly.

1. Gather all necessary information, including the employee's details, injury dates, and employer information.
2. Locate the section for the IC File #, Emp. Code #, Carrier Code #, and Carrier File #. Fill in these fields accurately.
3. In the Employer FEIN field, enter the Federal Employer Identification Number.
4. Fill in the employee’s Name, Address, City, State, and Zip code.
5. Provide the employee's Home Telephone and Work Telephone numbers.
6. Indicate the employee's Sex by marking either M or F.
7. Enter the employee's Date of Birth and Social Security Number.
8. Fill in the Employer's Name and Telephone Number.
9. Provide the Employer’s Address, City, State, and Zip code.
10. Fill in the Insurance Carrier and their Address, City, State, and Zip code.
11. Provide the Carrier's Telephone Number and Fax Number.
12. In SECTION A, enter the Date of injury, Date disability began, and Date returned to work.
13. If the employee returned to work for reduced wages, complete SECTION B by entering the rate of pay.
14. If the employee returned to work for a different employer, complete SECTION C by providing the Name, Address, and Telephone of that employer.
15. Have the Employer or Carrier/Administrator sign the form, and include their Title and Date.
16. Make sure to send the original form to the NCIC Claims Section and provide copies to the employee and their attorney, if applicable.

1. What is the North Carolina 28 form?

   The North Carolina 28 form, also known as the Return to Work Report, is a document used in workers' compensation cases. It is required when an employee returns to work after a period of disability due to an on-the-job injury. This form helps notify the North Carolina Industrial Commission (NCIC) about the employee's return status and any changes in their work situation.

2. When should I use the North Carolina 28 form?

   You should use the North Carolina 28 form when an employee returns to work after being off due to a work-related injury, but not on a trial return to work basis. If the employee is returning on a trial basis, you must use Form 28T instead. Ensure that the case does not fall under the exclusions outlined in NCIC Rule 404A(7) before using this form.

3. What information do I need to complete the form?

   The form requires several pieces of information, including:

   • Date of injury
   • Date disability began
   • Date returned to work
   • If applicable, the employee's reduced wage rate
   • If applicable, details about a different employer, including name, address, and telephone number

4. What happens if the employee returns to work for reduced wages?

   If the employee returns to work but is earning less than before their injury, you must indicate their new wage rate on the form. This information is crucial as it may affect their eligibility for partial disability compensation during their recovery period.

5. What should I do if the employee's trial return to work is unsuccessful?

   If the employee's trial return to work does not go well, they need to complete Form 28U. This form requests the reinstatement of their compensation. It is important to act promptly to ensure that the employee receives the benefits they are entitled to.

6. Where should I send the completed North Carolina 28 form?

   Once completed, the original form should be mailed to the NCIC Claims Section at 4335 Mail Service Center, Raleigh, NC 27699-4335. Additionally, a copy must be sent to the employee and their attorney of record, if applicable.

7. Is there a deadline for submitting the North Carolina 28 form?

8. Who is responsible for completing the form?

   The employer or the insurance carrier/administrator is responsible for completing the North Carolina 28 form. They must provide accurate information regarding the employee's return to work and any changes in their compensation.

9. How can I contact the NCIC for more information?

   You can reach the North Carolina Industrial Commission by calling their main telephone number at (919) 807-2500 or their helpline at (800) 688-8349. More information is also available on their website at http://www.ic.nc.gov/.

1. Failing to use the correct form for the situation. The North Carolina 28 form is not appropriate when an employee is returning to work on a trial basis. In such cases, Form 28T should be used instead.

2. Omitting essential information. It is crucial to fill in all required fields, including:

   • Date of injury
   • Date disability began
   • Date returned to work

   Missing any of this information can lead to delays or complications in processing the report.

3. Incorrectly reporting wage information. If the employee has returned to work for reduced wages, the form must clearly state the new wage rate. Failure to do so can result in inaccurate compensation calculations.

4. Not sending the form to the correct recipients. The original form must be sent to the NC Industrial Commission, while copies should be provided to the employee and their attorney, if applicable. Neglecting this step can cause legal and administrative issues.

The North Carolina 28 form is essential for reporting an employee's return to work following a workers' compensation claim. Alongside this form, several other documents are often required to ensure compliance with the Workers' Compensation Act. Below is a list of four key forms that may accompany the North Carolina 28 form.

• Form 28T: This form is used when an employee returns to work on a trial basis. It allows for a temporary return under specific conditions, providing the employee with partial disability compensation if their earnings are reduced due to their injury.
• Form 28U: If an employee's trial return to work is unsuccessful, this form is necessary to request the reinstatement of their disability compensation. It serves as a formal notification to the employer and the insurance carrier regarding the need to resume benefits.
• Form 28B: This form is utilized to report the amount of compensation paid to the employee and the last date such payments were made. It is crucial for maintaining accurate records of financial transactions related to the claim.
• Form IC-1: This is the initial claim form for workers' compensation in North Carolina. It must be filed to initiate the claim process and document the employee's injury and circumstances surrounding it.

Understanding these forms and their purposes is vital for both employees and employers. Proper documentation ensures that rights are protected and that all parties remain compliant with state regulations. Timely submission of these forms can significantly impact the outcome of a workers' compensation claim.

The North Carolina Form 28 is similar to the Form 28T, which is used for employees returning to work on a trial basis. The key difference lies in the circumstances of the return. While Form 28 is for employees who have returned to work without any trial conditions, Form 28T is specifically for those who are testing their ability to work after an injury. This distinction is crucial because the trial return to work allows for partial disability compensation if the employee's earnings are lower than before the injury, which is not applicable when using Form 28.

Another document similar to the Form 28 is the Form 28U. This form comes into play when an employee’s trial return to work is unsuccessful. It allows the employee to request the reinstatement of their compensation. While Form 28 confirms that an employee has returned to work, Form 28U serves as a mechanism to ensure that employees can regain their benefits if their return to work does not go as planned.

Form 19 is another relevant document. This form is used to report an employee’s injury to the North Carolina Industrial Commission. While Form 28 deals with the return to work process, Form 19 focuses on the initial reporting of the injury. Both forms are essential in the workers' compensation process, but they address different stages: one is for reporting injuries, and the other is for confirming a return to work.

Similar to the Form 19, Form 26 serves as a notice of compensation paid. This document provides a record of the benefits that have been issued to the employee following an injury. While Form 28 indicates the employee’s return to work status, Form 26 tracks the financial aspects of the compensation process, ensuring that all payments are documented and accounted for.

The Form 30 is also comparable, as it is used for filing a claim for additional compensation. This form is relevant when an employee believes they deserve more benefits due to ongoing issues from their injury. While Form 28 confirms the employee's return to work, Form 30 is a request for a reassessment of their compensation based on their current situation.

Form 24 is another document that shares similarities with Form 28. It is utilized by employers to request approval for terminating an employee's benefits. Both forms are part of the broader workers' compensation framework, but Form 24 focuses on the cessation of benefits, while Form 28 confirms the employee's transition back into the workforce.

Lastly, Form 21 is relevant as it is used to notify the Industrial Commission of a change in the employee's compensation status. This form is particularly important when there is a shift in the employee's work capacity or pay rate. While Form 28 indicates that the employee has returned to work, Form 21 ensures that any changes in compensation are formally communicated to the Commission, maintaining accurate records for all parties involved.

When filling out the North Carolina 28 form, it's crucial to follow certain guidelines to ensure that your submission is accurate and compliant. Here’s a helpful list of what to do and what to avoid.

• Do double-check all personal information for accuracy, including names, addresses, and Social Security numbers.
• Do ensure that you are not submitting this form if the employee is returning to work on a trial basis. In such cases, use Form 28T instead.
• Do provide the correct dates for the injury, the start of disability, and the return to work.
• Do include any information about reduced wages if applicable, specifying the weekly pay rate.
• Don't forget to sign the form. An unsigned form may delay processing.
• Don't send the form without making copies for the employee and their attorney, if they have one.

Following these dos and don’ts will help ensure that the process goes smoothly and that all parties are properly informed. Accuracy and attention to detail are key when handling workers' compensation documentation.

Misconceptions about the North Carolina 28 form can lead to confusion for both employers and employees. Here are five common misunderstandings:

• This form is for trial return to work situations. Many believe that the North Carolina 28 form can be used when an employee returns to work on a trial basis. In reality, this form is not appropriate for such cases. Instead, Form 28T should be utilized.
• Filing the form is optional. Some think that submitting the North Carolina 28 form is optional. However, it is a required document under the Workers' Compensation Act when an employee returns to work, excluding trial return situations.
• All employees returning to work need to complete this form. Not every employee returning to work needs to fill out the North Carolina 28 form. It is specifically for those who are not returning on a trial basis, as indicated in the instructions.
• Employers can delay submission of the form. There is a misconception that employers can take their time in submitting the North Carolina 28 form. Timely submission is crucial, as it ensures compliance with legal requirements and protects the rights of the employee.
• The form automatically reinstates compensation. Some believe that completing the North Carolina 28 form will automatically reinstate any disability compensation. This is not true. If an employee's trial return to work is unsuccessful, they must complete Form 28U to request reinstatement of compensation.

Filling out the North Carolina 28 form is crucial for managing workers' compensation claims effectively. Here are some key takeaways to keep in mind:

• Ensure accurate information: Double-check all details, including dates of injury and return to work, to avoid delays.
• Use the correct form: This form is not suitable for trial returns to work. Use Form 28T instead if applicable.
• Notify the employee: Inform the employee that their disability compensation has stopped due to their return to work.
• Send copies: After completing the form, send the original to the NC Industrial Commission and provide copies to the employee and their attorney.

Act promptly to ensure compliance and proper handling of the case. Missing details can lead to complications in the claims process.