11 NCAC 23L .0103 FORM 26A – EMPLOYER'S ADMISSION OF EMPLOYEE'S RIGHT TO PERMANENT PARTIAL DISABILITY (EFFECTIVE DECEMBER 1, 2020)
(a) The parties to a workers' compensation claim shall use the following Form 26A, Employer's Admission of Employee's Right to Permanent Partial Disability, for agreements regarding the employee's entitlement to and the employer's payment of compensation for permanent partial disability pursuant to G.S. 97-31. Additional issues agreed upon by the parties, such as election of payment of temporary partial disability pursuant to G.S. 97-30, may also be included on the form. This form is necessary to comply with Rule 11 NCAC 23A .0501, where applicable. The Form 26A, Employer's Admission of Employee's Right to Permanent Partial Disability, shall read as follows:
North Carolina Industrial Commission
Employer's Admission of Employee's Right to Permanent Partial Disability
(G.S. 97-31)
IC File # __________
Emp. Code # __________
Carrier Code # __________
Carrier File # __________
Employer FEIN __________
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
Social Security Number: _______ Sex: ‘ M ‘ 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 the 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 _____________________.
3. The injury by accident or occupational disease resulted in the following injuries: ______________________________________.
4. The employee ‘ was ‘ was not paid for the 7 day waiting period.
If not, was salary continued? ‘ yes ‘ no. Was employee paid for the date of injury? ‘ yes ‘ no
5. The average weekly wage of the employee at the time of the injury, including overtime and all allowances, was $_____________. This results in a weekly compensation rate of $____________.
6. The employee ‘ has ‘ has not returned full time to work for _________________________
on ________________________, at an average weekly wage of $__________________.
7. Claimant was released ‘ with permanent restrictions ‘ without permanent restrictions. If claimant was released with permanent restrictions and has returned to work for the employer of injury, attach a job description if known to exist.
8. Permanent partial disability compensation will be paid to the injured worker as follows:
____ weeks of compensation at rate of $________ per week for ____% rating to ___________ (body part)
____ weeks of compensation at rate of $________ per week for ____% rating to ___________ (body part)
____ weeks of compensation at rate of $________ per week for ____% rating to ___________ (body part)
Total amount of permanent partial disability compensation is $___________. Date of first payment:______________.
9. State any further matters agreed upon, including disfigurement, loss of teeth, election of temporary partial disability, waiting period or other: ___________________________________________________________________________________.
10. An overpayment is claimed in the amount of $________. Overpayment was calculated as follows:__________________________________________________.
If overpayment claimed, a Form 28B, Report of Compensation and Medical Compensation Paid, is attached. ‘ yes ‘ no
11. If applicable, the Second Injury Fund Assessment is $ ___________________. A check ‘ is ‘ is not included.
The undersigned hereby certify that the material medical and vocational records related to the injury, including any job description known to exist if the employee has permanent restrictions and has returned to work for the employer of injury, have been provided to the employee or the employee's attorney and have been filed with the Industrial Commission for consideration pursuant to G.S. 97-82(a) and Rule 11 NCAC 23A .0501.
_____________________________________________________________________________________________
Name Of Employer Signature Title Date
_____________________________________________________________________________________________
Name Of Carrier/Administrator Signature Direct Phone Number Email Address Title Date
By signing I enter into this agreement and certify that I have read the "Important Notices to Employee"
printed on Page 3 of this form.
_____________________________________________________________________________________________
Signature of Employee Address Email Address Date
_____________________________________________________________________________________________
Signature of Employee's Attorney Address Email Address Date
‘ Check box if no attorney retained.
North Carolina Industrial Commission
The Foregoing Agreement Is Hereby Approved:
_____________________________________________________________________________________________
Claims Examiner Date
_____________________________________________________________________________________________
Attorney's fee approved
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 apply to the Industrial Commission in writing within two years, or your right to these benefits may be lost. To apply you may also use Industrial Commission 18M, Employee's Application for Additional Medical Compensation (G.S. 97-25.1), available at http://www.ic.nc.gov/forms.html.
IMPORTANT NOTICE TO EMPLOYER
The employee must be provided a copy 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, or show cause for not submitting the agreement. 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 26A
12/2020
Self-Insured Employer or Carrier Mail to:
NCIC - Claims Administration
4335 Mail Service Center
Raleigh, North Carolina 27699-4335
Main Telephone: (919) 807-2500
Helpline: (800) 688-8349
Website: http://www.ic.nc.gov/
(b) A copy of the form described in Paragraph (a) of this Rule can be accessed at http://www.ic.nc.gov/forms/form26a.pdf. The form may be reproduced only in the format available at http://www.ic.nc.gov/forms/form26a.pdf and may not be altered or amended in any way.
History Note: Authority G.S. 97-30; 97-31; 97-73; 97-80(a); 97-81(a); 97-82; S.L. 2014-77;
Eff. November 1, 2014;
Recodified from 04 NCAC 10L .0103 Eff. June 1, 2018;
Amended Eff. December 1, 2020.
11 NCAC 23L .0103 FORM 26A – EMPLOYER'S ADMISSION OF EMPLOYEE'S RIGHT TO PERMANENT PARTIAL DISABILITY (eFFECTIVE MARCH 1, 2021)
(a) The parties to a workers' compensation claim shall use the following Form 26A, Employer's Admission of Employee's Right to Permanent Partial Disability, for agreements regarding the employee's entitlement to and the employer's payment of compensation for permanent partial disability pursuant to G.S. 97-31. Additional issues agreed upon by the parties, such as election of payment of temporary partial disability pursuant to G.S. 97-30, may also be included on the form. This form is necessary to comply with Rule 11 NCAC 23A .0501, where applicable. The Form 26A, Employer's Admission of Employee's Right to Permanent Partial Disability, shall read as follows:
North Carolina Industrial Commission
Employer's Admission of Employee's Right to Permanent Partial Disability
(G.S. 97-31)
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 the 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 _____________________.
3. The injury by accident or occupational disease resulted in the following injuries: ______________________________________________________________________________.
4. The employee o was o was not paid for the 7 day waiting period.
If not, was salary continued? o yes o no. Was employee paid for the date of injury? o yes o no
5. The average weekly wage of the employee at the time of the injury, including overtime and all allowances, was $_____________. This results in a weekly compensation rate of $____________.
6. The employee o has o has not returned full time to work for _________________________
on ________________________, at an average weekly wage of $__________________.
7. Claimant was released o with permanent restrictions o without permanent restrictions. If claimant was released with permanent restrictions and has returned to work for the employer of injury, attach a job description if known to exist.
8. Permanent partial disability compensation will be paid to the injured worker as follows:
____ weeks of compensation at rate of $________ per week for ____% rating to ___________ (body part)
____ weeks of compensation at rate of $________ per week for ____% rating to ___________ (body part)
____ weeks of compensation at rate of $________ per week for ____% rating to ___________ (body part)
Total amount of permanent partial disability compensation is $___________. Date of first payment:______________.
9. State any further matters agreed upon, including disfigurement, loss of teeth, election of temporary partial disability, waiting period or other: ___________________________________________________________________________________.
10. An overpayment is claimed in the amount of $_______________. Overpayment was calculated as follows:_______________________________________________________________________.
If overpayment claimed, a Form 28B, Report of Compensation and Medical Compensation Paid, is attached. o yes o no
11. If applicable, the Second Injury Fund Assessment is $ ___________________. A check o is o is not included.
The undersigned hereby certify that the material medical and vocational records related to the injury, including any job description known to exist if the employee has permanent restrictions and has returned to work for the employer of injury, have been provided to the employee or the employee's attorney and have been filed with the Industrial Commission for consideration pursuant to G.S. 97-82(a) and Rule 11 NCAC 23A .0501.
_____________________________________________________________________________________________
Name Of Employer Signature Title Date
_____________________________________________________________________________________________
Name Of Carrier/Administrator Signature Direct Phone Number Email Address Title Date
By signing I enter into this agreement and certify that I have read the "Important Notices to Employee"
printed on Page 3 of this form.
_____________________________________________________________________________________________
Signature of Employee Address Email Address Date
_____________________________________________________________________________________________
Signature of Employee's Attorney Address Email Address Date
o Check box if no attorney retained.
North Carolina Industrial Commission
The Foregoing Agreement Is Hereby Approved:
_____________________________________________________________________________________________
Claims Examiner Date
_____________________________________________________________________________________________
Attorney's fee approved
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 26A
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) A copy of the form described in Paragraph (a) of this Rule can be accessed at https://www.ic.nc.gov/forms/form26a.pdf. The form may be reproduced only in the format available at https://www.ic.nc.gov/forms/form26a.pdf and may not be altered or amended in any way.
History Note: Authority G.S. 97-30; 97-31; 97-73; 97-80(a); 97-81(a); 97-82; S.L. 2014-77;
Eff. November 1, 2014;
Recodified from 04 NCAC 10L .0103 Eff. June 1, 2018;
Amended Eff. December 1, 2020;
Amended Eff. March 1, 2021.