Employees Request That Compensation Be Reinstated After Unsuccessful Trial Return To Work {28U}

FORM 28U 10/2017 PAGE 1 OF 1 A TTORNEYS/CARRIERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML EMPLOYEE FILING OPTIONS: E-MAIL TO EXECSEC@IC.NC.GOV FAX TO (919) 715-0282 MAIL TO NCIC-EXECUTIVE SECRETARY 1236 MAIL SERVICE CENTER RALEIGH, NC 27699-1236 HELPLINE: (800) 688-8349 WEBSITE: HTTP:/ / WWW.IC.NC.GOVFORM 28U North Carolina Industrial Commission IC File # E MPLOYEE'S REQUEST THAT COMPENSATION BE Emp. Code # R EINSTATED AFTER UNSUCCESSFUL TRIAL RETURN Carrier Code # TO WORK (G.S. 247 97-32.1) Employer FEIN The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act ( ) Employee222s Name Employer's Name Telephone Number A dd r ess Employer222s Address City State Zip City State ZipInsurance Carrier ( ) ( ) Home Telephone Work TelephoneCarrier's Address City State Zip XXX-XX- M F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth Carrier's Telephone Number Fax Number SECTION A. EMPLOYEE: COMPLETE AND MAIL TO EMPLOYER AND CARRIER /A DMINISTRATOR, AND TO THE INDUSTRIAL COMMISSION AT THE A DDRESS BELOW: 1. I request that my total disability compensation be resumed immediately. I had a trial return to work with (name of employer) from (date first worked) until (date last worked). The date of m y in j ur y b y accident or the date of disabilit y from m y occupational disease was 2. Explain in detail the reasons y ou are no lon g er workin g : 3. The employee MUST obtain the following from an authorized treating physician: TREATING PHYSICIAN222S STATEMENT This is to certify that the employee is unable to continue the trial return to work due to the employee222s injury for which compensation has been paid. M y medical specialt y is: SIGNATURE OF AUTHORIZED TREATING PHYSICIAN PRINTED NAMEDATE ADDRESS CITY STATE ZIP IF RETURN TO WORK WAS WITH THE EMPLOYER FROM WHOM YOU HAVE RECEIVED WORKERS222 COMPENSATION, SIGN HERE AND DO NOT COMPLETE THE REMAINDER OF THIS FORM. IF RETURN TO WORK WAS WITH A DIFFERENT EMPLOYER, COMPLETE SECTION B BELOW. SIGNATURE OF EMPLOYEE DATE SECTION B. EMPLOYEE'S RELEASE OF EMPLOYMENT INFORMATION I hereb y request and authorize m y last emplo y er, (Name and address of last employer) to release to my prior employer and carrier/administrator listed above, or their attorney of record, the following information relating to my trial return to work: first and last date worked, total wages earned, and the reasons this employee is no longer so employed.READ BEFORE SIGNING SIGNATURE OF EMPLOYEEDATE SEND A COPY OF THIS FORM TO THE EMPLOYER AND CARRIER/ADMINISTRATOR FROM WHOM YOU WERE RECEIVING WORKERS222 COMPENSATION. SEND THE ORIGINAL TO THE INDUSTRIAL COMMISSION AT THE ADDRESS BELOW. American LegalNet, Inc. www.FormsWorkFlow.com