Get the free Statement of Workers’ Compensation Benefits and Obligations

This document is a sworn statement required by North Carolina statutes for self-insurers to report their workers' compensation benefits paid and outstanding liabilities for the fiscal year.

How to fill out statement of workers compensation

How to fill out Statement of Workers’ Compensation Benefits and Obligations

1. Obtain the Statement of Workers’ Compensation Benefits and Obligations form from your employer or the state workers' compensation board.
2. Fill in your personal information, including your name, address, and contact details at the top of the form.
3. Provide details about your employment, such as your job title, the name of your employer, and your date of hire.
4. Clearly state the date of your injury or illness and describe how it occurred in the designated section.
5. List all medical treatments you have received, including the names of healthcare providers and dates of treatment.
6. Indicate your current status regarding recovery, including any work restrictions or return-to-work information.
7. Attach any necessary supporting documents, such as medical records or bills related to your injury.
8. Review the entire form for accuracy and completeness before submission.
9. Sign and date the form in the appropriate section to verify the information provided.
10. Submit the completed form to your employer or their insurance carrier as instructed.

Who needs Statement of Workers’ Compensation Benefits and Obligations?

1. Employees who have sustained work-related injuries or illnesses.
2. Employers who need to report and manage workers' compensation claims.
3. Insurance companies that process claims and determine benefits.
4. Healthcare providers who need to understand the benefits available to their patients.

For pdfFiller’s FAQs

What is Statement of Workers’ Compensation Benefits and Obligations?

The Statement of Workers’ Compensation Benefits and Obligations is a document that outlines the benefits provided to injured workers under workers' compensation laws, as well as the responsibilities and obligations of both the employer and the employee regarding those benefits.

Who is required to file Statement of Workers’ Compensation Benefits and Obligations?

Employers who are obligated to provide workers' compensation benefits to their employees are required to file this statement. It is also necessary for employees who receive benefits to ensure compliance with the stated obligations.

How to fill out Statement of Workers’ Compensation Benefits and Obligations?

To fill out the Statement of Workers’ Compensation Benefits and Obligations, the employer must provide detailed information about the employee's injury, the benefits being offered, and any obligations the employee must meet, such as attending medical appointments or providing medical documentation.

What is the purpose of Statement of Workers’ Compensation Benefits and Obligations?

The purpose of this statement is to ensure transparency between employers and employees regarding workers' compensation benefits. It helps clarify the rights and responsibilities of each party and ensures compliance with legal requirements.

What information must be reported on Statement of Workers’ Compensation Benefits and Obligations?

The statement must report information including the nature of the injury, the type of benefits provided (such as medical care or wage loss), any obligations of the employee (like reporting changes in medical condition), and deadlines for submitting required documentation.