Loading
Form preview picture

Get North Carolina Form 25t 2019-2024

FORM 25T 01/2019 PAGE 1 OF 1 NOTICE TO INJURED EMPLOYEE THIS FORM SHOULD BE RETURNED TO THE CARRIER AT THE ADDRESS ABOVE FOR PAYMENT. North Carolina Industrial Commission IC File ITEMIZED STATEMENT OF CHARGES FOR TRAVEL Emp* Code Carrier Code Carrier File The Use of This Form Is Required Under the Provisions of the Workers Compensation Act Employer FEIN Employee s Name Address Employer s Address City State - Home Telephone Zip Telephone Number Insurance Carrier Work Telephone Carrier s Address Carrier s Telephone Number Fax Number Employees are entitled to reimbursement of 0. 58 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2019. Special consideration will be given to employees who are totally disabled* No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. These items must be purchased on visits to medical providers G*S* 97-25. DATE / NAME OF MEDICAL PROVIDER OTHER EXPENSES If overnight stay is necessary the following items will be approved as submitted* Receipts must be furnished for carrier s file. TOTAL MILES ROUNDTRIP CITY Total Miles Total motel expense actual up to 71. 20 per day in-state or 84. 10 per day out-of-state and 18. 90 in-state or 21. 60 out-of-state Dinner Total parking cab expense actual charge Total for other expenses X mileage rate Other expenses Total all expenses Prior mileage rates are as follows a 0. 545 for 2018 b 0. 535 for 2017 c 0. 54 for 2016 d 0. 575 for 2015 e 0. 56 for 2014 I hereby certify that I have incurred all expenses listed above as a result of my workers compensation injury. Employee signature Carrier s approval Employee Mail your bill in duplicate promptly to employer and/or Employer or Carrier/Administrator Travel may be reimbursed directly to the employee. It is not necessary to submit bills to the Commission for approval* Pay and retain copy in carrier s file. North Carolina Industrial Commission IC File ITEMIZED STATEMENT OF CHARGES FOR TRAVEL Emp* Code Carrier Code Carrier File The Use of This Form Is Required Under the Provisions of the Workers Compensation Act Employer FEIN Employee s Name Address Employer s Address City State - Home Telephone Zip Telephone Number Insurance Carrier Work Telephone Carrier s Address Carrier s Telephone Number Fax Number Employees are entitled to reimbursement of 0. 58 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2019. 58 per mile for travel for medical treatment provided they travel 20 miles or more roundtrip starting January 1 2019. Special consideration will be given to employees who are totally disabled* No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. Special consideration will be given to employees who are totally disabled* No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. These items must be purchased on visits to medical providers G*S* 97-25. DATE / NAME OF MEDICAL PROVIDER OTHER EXPENSES If overnight stay is necessary the following items will be approved as submitted* Receipts must be furnished for carrier s file. .

How It Works

25 t form rating
4.8Satisfied
235 votes

Tips on how to fill out, edit and sign Nc form 25t online

How to fill out and sign North carolina industrial commission form 25t online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Finding a legal expert, making a scheduled appointment and going to the office for a private meeting makes completing a NC IC Form 25T from start to finish tiring. US Legal Forms helps you to rapidly make legally valid papers based on pre-constructed browser-based samples.

Perform your docs within a few minutes using our straightforward step-by-step guide:

  1. Get the NC IC Form 25T you require.
  2. Open it up using the online editor and start altering.
  3. Complete the empty fields; concerned parties names, addresses and phone numbers etc.
  4. Change the template with unique fillable areas.
  5. Add the day/time and place your e-signature.
  6. Simply click Done following double-examining everything.
  7. Save the ready-created record to your gadget or print it as a hard copy.

Rapidly produce a NC IC Form 25T without needing to involve professionals. We already have more than 3 million customers making the most of our unique library of legal forms. Join us today and get access to the #1 collection of web blanks. Try it yourself!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing nc industrial commission form 25t

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to ncic 25t

  • nc ic
  • nc industrial commission 25t
  • ic form
  • nc industrial commission forms
  • statement of charges form
  • workers compensation form 25t for north carolina 2022
  • workers' comp mileage form 25t
  • nc form25t 01 2022
  • nc 25t form
  • itemized statement charges
  • 2013 25t
  • form statement charges
  • form 25t nc
  • form 25t mileage
  • form 25t fillable
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.