11 NCAC 23A .0902         Notice

A self-insured employer, carrier or third party administrator shall not use check endorsement language on the back of an employee's workers' compensation benefit check unless the employee has been provided the following Notice sent by certified mail return receipt requested:




This NOTICE is intended to advise you of important information you must know if you are receiving workers' compensation benefits.

Please TAKE NOTICE of the following:

(a)  When you are receiving weekly workers' compensation benefits, you must report any earnings you receive to the insurance company (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).  Incentives, commissions, bonuses, or other compensation earned before disability but received during the time you are also receiving workers' compensation benefits do not constitute earnings that must be reported.

(b)  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.

(c)  Your endorsement on a benefit check or deposit of the check into an account is your certification that you have not worked for or earned wages from any business or individual during the period covered by the check, or that you have reported any earnings to the employer or carrier paying you workers' compensation benefits and that you are entitled to receive workers' compensation benefits.  Your signature on a benefit check is further certification that you have made no material false statement or concealed any material fact regarding your right to receive the benefit check.

(d)  Making false statements for the purpose of obtaining workers' compensation benefits may result in civil and criminal penalties.


History Note:        Authority G.S. 97-80(a); 97-88.2;

Eff. June 1, 2000;

Amended Eff. November 1, 2014;

Recodified from 04 NCAC 10A .0902 Eff. June 1, 2018.