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FORM 17Revised 10/2017 N. C. WORKERS COMPENSATION NOTICE TO INJURED WORKERS AND EMPLOYERS All employees of this business, except specifically excluded executive officers, suffering work related injuries
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How to fill out nc workers compensation notice

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How to fill out nc workers compensation notice

01
To fill out the NC Workers Compensation Notice, follow these steps:
02
Start by entering the name of the injured employee in the designated field.
03
Provide the employee's Social Security Number (SSN) for identification purposes.
04
Specify the date and time of the accident or injury.
05
Describe the nature and details of the injury or illness in a clear and concise manner.
06
Indicate whether the employee received medical treatment for the incident.
07
If medical treatment was provided, mention the healthcare provider's name and address.
08
Enter the date of the first missed workday due to the injury.
09
Provide details about the employee's regular job and duties.
10
Confirm whether the employee has returned to work or is still on leave.
11
If the employee is on leave, specify the estimated duration of the leave.
12
Finally, sign and date the notice to validate the information provided.
13
Make sure to review the completed form for accuracy and completeness before submission.

Who needs nc workers compensation notice?

01
The NC Workers Compensation Notice is required for employers in North Carolina who have employees covered by workers' compensation insurance.
02
It is necessary for all employers to provide this notice to workers who have been injured on the job or developed an occupation-related illness.
03
The notice helps ensure that employees are aware of their rights and benefits under the workers' compensation program.
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The NC Workers' Compensation Notice is a formal document that notifies an injured employee of their rights and benefits under the North Carolina Workers' Compensation Act.
Employers who are required to carry workers' compensation insurance in North Carolina must file the NC Workers' Compensation Notice.
To fill out the NC Workers' Compensation Notice, employers need to provide details about the employee, the accident, any medical treatment, and the employer's insurance information according to the provided guidelines.
The purpose of the NC Workers' Compensation Notice is to inform employees of their rights to compensation and medical benefits following a work-related injury or illness.
The notice must report the employee's name, address, date of injury, nature of injury, medical treatment information, and details regarding the employer's insurance coverage.
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