SUBCHAPTER 23L – INDUSTRIAL COMMISSION FORMS
SECTION .0100 – WORKERS’ COMPENSATION FORMS
11 NCAC 23L .0101 FORM 21 – AGREEMENT FOR COMPENSATION FOR DISABILITY
(a) The parties to a workers' compensation claim shall use the following Form 21, Agreement for Compensation for Disability, for agreements regarding disability and payment of compensation therefor pursuant to G.S. 97-29 and 97-30. Additional issues agreed upon by the parties such as payment of compensation for permanent partial disability may also be included on the form. This form is necessary to comply with Rule 11 NCAC 23A .0501, where applicable. The Form 21, Agreement for Compensation for Disability, shall read as follows:
North Carolina Industrial Commission
Agreement for Compensation for Disability
(G.S. 97-82)
IC File # __________
Emp. Code # __________
Carrier Code # __________
Carrier File # __________
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
____________________________________________________________
Employee's Name
____________________________________________________________
Address
____________________________________________________________
City State Zip
____________________________________________________________
Home Telephone Work Telephone
Last 4 digits of Social Security Number: _______ Sex: o M o F Date of Birth: _______
____________________________________________________________
Employer's Name Telephone Number
____________________________________________________________
Employer's Address City State Zip
____________________________________________________________
Insurance Carrier
____________________________________________________________
Carrier's Address City State Zip
____________________________________________________________
Carrier's Telephone Number Carrier's Fax Number
We, The Undersigned, Do Hereby Agree And Stipulate As Follows:
1. All parties hereto are subject to and bound by the provisions of the Workers' Compensation Act and __________ is the carrier/administrator for the employer.
2. The employee sustained an injury by accident or the employee contracted an occupational disease arising out of and in the course of employment on or by __________.
3. The injury by accident or occupational disease resulted in the following injuries: __________
________________________________________________________________________________.
4. The employee o was/ o was not paid for the entire day when the injury occurred.
5. The average weekly wage of the employee at the time of the injury, including overtime and all allowances, was $________, subject to verification unless otherwise agreed upon in Item 9 below.
6. Disability resulting from the injury or occupational disease began on ________.
7. The employer and carrier/administrator hereby undertake to pay compensation to the employee at the rate of $________ per week beginning ________, and continuing for ________ weeks.
8. The employee o has / o has not returned to work for ________________________________
on ________________ , at an average weekly wage of $________.
9. State any further matters agreed upon, including disfigurement, permanent partial, or temporary partial disability: ________________________________________________________________.
10. If applicable, the Second Injury Fund Assessment is $________. Check o is o is not attached.
11. The date of this agreement is ________. Date of first payment: ________ Amount: ________.
__________________________________________________________________________________
Name Of Employer Signature Title
__________________________________________________________________________________
Name Of Carrier / Administrator Signature Title
By signing I enter into this agreement and certify that I have read the “Important Notices to Employee” printed on Page 2 of this form.
__________________________________________________________________________________
Signature of Employee Address
__________________________________________________________________________________
Signature of Employee's Attorney Address
North Carolina Industrial Commission
The Foregoing Agreement Is Hereby Approved:
___________________________________________
Claims Examiner Date
___________________________________________
Attorney's Fee Approved
o Check Box If No Attorney Retained.
o Check Box If Employee Is In Managed Care.
IMPORTANT NOTICE TO EMPLOYEE CLAIMING ADDITIONAL WEEKLY CHECKS OR LUMP SUM PAYMENTS
Once your compensation checks have been stopped, if you claim further compensation, you must notify the Industrial Commission in writing within two years from the date of receipt of your last compensation check or your rights to these benefits may be lost.
IMPORTANT NOTICE TO EMPLOYEE INJURED BEFORE JULY 5, 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS
If your injury occurred before July 5, 1994, you are entitled to medical compensation as long as it is reasonably necessary, related to your workers' compensation case, and authorized by the carrier or the Industrial Commission.
IMPORTANT NOTICE TO EMPLOYEE INJURED ON OR AFTER JULY 5, 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS
If your injury occurred on or after July 5, 1994, your right to future medical compensation will depend on several factors. Your right to payment of future medical compensation will terminate two years after your employer or carrier/administrator last pays any medical compensation or other compensation, whichever occurs last. If you think you will need future medical compensation, you must file an application for additional medical compensation pursuant to G.S. 97-25.1 within two years, or your right to these benefits may be lost. An application for additional medical compensation may be made on a Form 18M Employee’s Application for Additional Medical Compensation or by written request. In the alternative, an employee may file an application for additional medical compensation by filing a Form 33 Request that Claim be Assigned for Hearing pursuant to 11 NCAC 23A .0602. All Industrial Commission forms are available at https://www.ic.nc.gov/forms.html.
IMPORTANT NOTICE TO EMPLOYER
The employee must be provided a copy of the form when the agreement is signed by the employee. Pursuant to Rule 11 NCAC 23A .0501, within 20 days after receipt of the agreement executed by the employee, the employer or carrier/administrator must submit the agreement to the Industrial Commission. The employer or carrier/administrator shall file a Form 28B, Report of Compensation and Medical Compensation Paid, within 16 days after the last payment made pursuant to this agreement or be subject to a penalty.
NEED ASSISTANCE?
If you have questions or need help and you do not have an attorney, you may contact the Industrial Commission at (800) 688-8349.
Form 21
3/2021
Self-Insured Employer or Carrier, File via Electronic Document Filing Portal ("EDFP"):
https://www.ic.nc.gov/docfiling.html
Contact Information:
NCIC- Claims Administration
Telephone: (919) 807-2502
Helpline: (800) 688-8349
Website: https://www.ic.nc.gov
(b) The copy of the form described in Paragraph (a) of this Rule can be accessed at https://www.ic.nc.gov/forms/form21.pdf. The form may be reproduced only in the format available at https://www.ic.nc.gov/forms/form21.pdf and may not be altered or amended in any way.
History Note: Authority G.S. 97-73; 97-80(a); 97-81(a); 97-82; S.L. 2014-77;
Eff. November 1, 2014;
Recodified from 04 NCAC 10L .0101 Eff. June 1, 2018;
Amended Eff. March 1, 2021.