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SELF-INSURED EMPLOYER OR CARRIER MAIL TO FORM 22 10/2006 PAGE 1 OF 2 NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH NC 27699-4335 TELEPHONE 919 807-2502 HELPLINE 800 688-8349 WEBSITE HTTP //WWW.IC. North Carolina Industrial Commission IC File STATEMENT OF DAYS WORKED AND EARNINGS OF INJURED EMPLOYEE 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 - Telephone Number Employer s Address State Home Telephone / M Date of Injury Zip City F Sex Date of Birth Carrier s Address Carrier s Telephone Number Fax Number Insurance Carrier Work Telephone Social Security Number Year 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Amount Earned Jan. Feb. NC. GOV/ The undersigned employer of Name of Employee who alleges an injury on the of Day Month while in the employment of the undersigned does hereby certify that the above is a true and correct statement of days worked and earnings of this employee during the 52 weeks immediately preceding the injury or during the above weeks and parts thereof if employed for less than 52 weeks and while engaged in the occupation in which the employee was allegedly injured. Employer By Authorized Signature /200 Date Signed To Employer Making a false statement for the purpose of denying workers compensation benefits may result in civil or criminal penalties. Mar* Apr* May June July Aug. Sept. Oct. Nov* Dec* Total Was this employee given free rent lodging or board or other allowances made in lieu of wages If so state weekly value thereof. INSTRUCTIONS This form must be completed and filed with the Commission in all cases resulting in death unless maximum compensation rate is stipulated* It must also be filed in any other case if there is a disagreement about earnings or if the Commission requests it. In preparing this form place an X in the proper squares to indicate days paid in full* Days the employee is on paid vacation leave and/or paid sick leave should be marked with an X. Leave blank squares to indicate days not paid in full for any reason* Total earnings for each pay period should be placed in the proper column* If the employee s job or pay rate was changed during the reported period this should be noted with an indication as to the nature of the change. The employer code number and the carrier code number if any must be inserted in the proper place at the upper right-hand corner of the form*. INSTRUCTIONS This form must be completed and filed with the Commission in all cases resulting in death unless maximum compensation rate is stipulated* It must also be filed in any other case if there is a disagreement about earnings or if the Commission requests it. In preparing this form place an X in the proper squares to indicate days paid in full* Days the employee is on paid vacation leave and/or paid sick leave should be marked with an X. In preparing this form place an X in the proper squares to indicate days paid in full* Days the employee is on paid vacation leave and/or paid sick leave should be marked with an X. Leave blank squares to indicate days not paid in full for any reason* Total earnings for each pay period should be placed in the proper column* If the employee s job or pay rate was changed during the reported period this should be noted with an indication as to the nature of the change.