North Carolina Industrial Commission IC File#
  Emp. Code
To the Employer:
The filing of this report is required by law. It does not satisfy the employee's obligation to file a claim.
               This Form MUST be transmitted to the Industrial Commission through Your Insurance Carrier.
Carrier File#
To the Employee:
This Form 19 is not your claim for workers' compensation benefits. To make a claim, you must complete and sign the enclosed Form 18 and mail it to Claims Administration, N.C. Industrial Commission, 4334 Mail Service Center, Raleigh, NC 28799-4334 within two years of the date of your injury or last payment of medical compensation. For occupational diseases, the claim must be filed within two years of the date of disability and the date your doctor told you that you have a work-related disease, whichever is later.
The I.C. File # is the unique identifier for this injury. It will be provided by the return letter and is to be referenced in all future correspondence.
The use of this form is required under the provisions of the Workers' Compensation Act.

Employee's Name

Employer's Name                                                             Employer's Telephone


Employer's Address                                                                       State  Zip Code

City                                                                                     State   Zip Code

Insurance Carrier                                                       Policy Number


Home Telephone                                                 Work Telephone

Carrier's Address                                                                           State  Zip Code


Social Security Number                  Sex           Date of Birth

Carrier's Telephone Number                     Fax Number

 Employer  1. Give the nature of employers business
 2. Location of plant where injury occurred
 Time      County Department State if employer's premises
 And  3. Date of Injury   4. Day of week   Hour of day AMPM
 Place  5. Was employee paid for entire day   6. Date disability began AMPM
   7. Date you or the supervisor first knew of the injury   8. Name of supervisor
 9. Occupation when injured 
 Person 10. (a) Time employed by you   (b) Wages per hour  $
 Injured 11. (a). No. hours worked per day    (b) Wages per day $ (c) No. of days worked per week
        (d) Avg. weekly wages w/ overtime $   (e) If board, lodging, fuel or other advantages were
        furnished in addition to to wages,  estimated value per day, week or month. $ per
12. Describe fully how injury occurred and what employee was doing when injured

(Statement made without prejudice and without vouching for correctness of information)

 Nature 13. List all injuries and specify body part involved (e.g. right hand or left hand)
 of Injury  
14. Date & hour returned to work at .M.  15. If so, at what wages $ per
16. At what occupation  17. Employee's salary continued in full?
18. Was employee treated by a physician
 Fatal Cases 19. Has injured employee died 20. If so, give date of death (Submit Form 29)
 Employer's Name      Date Completed
 Signed by             Official Title
 OSHA 301 Information
Case Number from Log: Date Hired Time Employee began work on date of incident If off-site medical treatment provided, answer entire next line
Name of facility Address: Street/City/Zip/Telephone ER visit? Overnight stay?     
Yes.No  YesNo
Attention:  This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.