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This document is a required report for self-insurers in North Carolina to state their total workers' compensation benefits paid and outstanding liabilities after their self-insured privilege has been

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 relevant workers' compensation board.
2. Fill in your personal information, including your name, address, and contact details.
3. Provide details about your employer, such as the company name and address.
4. Include information about your work-related injury or illness, stating the date it occurred and the nature of the injury.
5. Document any medical treatments you've received related to your injury or illness, including the names of healthcare providers.
6. Indicate any benefits you have already received or are currently receiving.
7. Sign and date the form to certify that the information is accurate to the best of your knowledge.
8. Submit the completed form to the appropriate workers' compensation agency or your employer as instructed.

Who needs Statement of Workers’ Compensation Benefits and Obligations?

1. Workers who have sustained injuries or illnesses in the course of their employment may need to fill out this statement to claim benefits.
2. Employers may also need this document to understand their obligations and to manage claims.
3. Insurance companies involved in workers' compensation may require this statement for processing claims.
4. Legal representatives of injured workers may need this document to assist their clients with claims.

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.