Form 19

The Form 19 is used by self-insured employers or carriers in North Carolina to report employee injuries or occupational diseases to the Industrial Commission. It must be accompanied by a blank Form 18 and given to the employee. To make a claim for workers' compensation benefits, the employee must complete and sign Form 18 and mail it to Claims Administration at the North Carolina Industrial Commission within two years of the injury or last payment of medical compensation.

Self-insured employers or carriers reporting injuries.

The completed Form 19 should be submitted to the North Carolina Industrial Commission through an insurance carrier.