Supplemental Agreement As To Payment Of Compensation {26}

FORM 26 06/2018 PAGE 1 OF 2 A TTORNEYS/CARRIERS/SELF-INSURED EMPLOYERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML HELPLINE: (800) 688-8349 WEBSITE: HTTP:/ / WWW.IC.NC.GOV / FORM 26 North Carolina Industrial Commission IC File # S UPPLEMENTAL AGREEMENT AS TO PAYMENT Emp. Code # OF COMPENSATION (G.S. 247 97-82) Carrier Code # The Use of This Form Is Required Under the Provisions of the Workers' Compensation ActCarrier File # Employer FEIN ( ) Employee222s Name Employer's Name Telephone Number A ddress 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 WE, THE UNDERSIGNED, DO HEREBY A GREE AND STIPULATE A S FOLLOWS: 1. Date of injury: 2. The employee returned to work / was rated on (date), at a weekly wage of $ . 3. The employee became totally disabled on . 4. Employee222s average weekly wage was reduced / was increased on , from $ per week to $ per week. 5. The employer and carrier/administrator hereby undertake to pay compensation to the employee at the rate of $ per week beginning , and continuing fo r weeks. The type of disability compensation is 6. State any further matters agreed upon, including disfigurement or temporary partial disability: 7. The date of this agreement is . NAME OF EMPLOYER SIGNATURETITLE NAME OF CARRIER/ADMINISTRATOR SIGNATURETITLE By signing I enter into this agreement and certify that I have read the 223Important Notices to Employee224 printed on Page 2 of this form. SIGNATURE OF EMPLOYEE ADDRESS SIGNATURE OF EMPLOYEE222S ATTORNEY ADDRESS Check box if no attorney retained. NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING AGREEMENT IS HEREBY APPROVED: CLAIMS EXAMINER DATE ATTORNEY222S FEE APPROVED American LegalNet, Inc. www.FormsWorkFlow.com FORM 26 06/2018 PAGE 2 OF 2 A TTORNEYS/CARRIERS/SELF-INSURED EMPLOYERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML HELPLINE: (800) 688-8349 WEBSITE: HTTP:/ / WWW.IC.NC.GOV / FORM 26 IMPORTANT NOTICE TO EMPLOYEE CLAIMING ADDITIONAL WEEKLY CHECKS OR LUMP SUM PAYMENTS Once your compensation checks have been stopped, if you claim further compensation, you must notify the Industrial Commission in writing within two years from the date of receipt of your last compensation check or your rights to these benefits ma y be lost. IMPORTANT NOTICE TO EMPLOYEE INJURED BEFORE JULY 5, 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS If your injury occurred before July 5, 1994, you are entitled to medical compensation as long as it is reasonably necessary, related to your workers222 compensation case, and authorized by the carrier or the Industrial Commission. IMPORTANT NOTICE TO EMPLOYEE INJURED ON OR AFTER JULY 5, 1994 CLAIMING ADDITIONAL MEDICAL BENEFITS If your injury occurred on or after July 5, 1994, your right to future medical compensation will depend on several factors. Your right to payment of future medical compensation will terminate two years after your employer or carrier/administrator last pays any medical compensation or other compensation, whichever occurs last. If you think you will need future medical compensation, you must apply to the Industrial Commission in writing within two years, or your right to these benefits may be lost. To apply you may also use Industrial Commission Form 18M, Employee222s Application for Additional Medical Compensation (G.S. 97-25.1), available at http://www.ic.nc.gov/forms.html. IMPORTANT NOTICE TO EMPLOYER This form shall be used only to supplement Form 21, Agreement for Compensation for Disability (G.S. 97-82), or an award in cases in which subsequent conditions require a modification of a former agreement or award. The employee must be provided a copy of the form when the agreement is signed by the employee. Pursuant to Rule 11 NCAC 23A .0501, within 20 days after receipt of the agreement executed by the employee, the employer or carrier/administrator must submit the agreement to the Industrial Commission, or show cause for not submitting the agreement. The employer or carrier/administrator shall file a Form 28B, Report of Compensation and Medical Compensation Paid, within 16 days after the last payment made pursuant to this a g reement or be sub j ect to a penalt y . NEED ASSISTANCE? If you have questions or need help and you do not have an attorney, you may contact the Industrial Commission at (800) 688-8349. American LegalNet, Inc. www.FormsWorkFlow.com