North Carolina Industrial Commission Form 28C is the final accounting an employer or insurance carrier files after paying out a workers’ compensation claim that ended in a compromise settlement agreement. You must file it with the Commission and serve a copy on the injured worker within 16 days of the last compensation payment. Filing starts a two-year clock on the worker’s right to seek further medical benefits, and missing the deadline carries a $25 civil penalty. The current version of the form is dated March 2020 and is available as a PDF from the Commission’s forms page at ic.nc.gov.
When to Use Form 28C Instead of Form 28B
Confirm you have the right form before filling anything in. Under N.C. Gen. Stat. § 97-18(h), the Commission uses two separate closing forms: Form 28B for claims that concluded through a standard compensation agreement or award, and Form 28C for claims resolved through a compromise settlement agreement.1North Carolina Industrial Commission. North Carolina General Statute 97-18 – Prompt Payment of Compensation Required The header on Form 28C itself says “This Form Is Only To Be Used In Settled Cases.” Filing the wrong form will delay the close of the file, and because the statutory notice requirement is not satisfied, the two-year medical clock may not start running at all.
How to Complete Form 28C
The form is a single page: identification fields across the top, a numbered financial summary in the middle, and a signature block at the bottom. Before you begin, pull the approved compromise settlement agreement, your internal payment ledger, and any prior Form 21 or Form 26 so you can reconcile every figure.
Identification Fields
The top of the form asks for four reference numbers: the IC File # (the Commission’s case number, which should match prior filings exactly), the Emp. Code #, the Carrier Code #, and the Carrier File #. Below those, enter the employee’s full legal name, address, home and work telephone numbers, the last four digits of their Social Security number, sex, and date of birth. Then fill in the employer’s name and address, followed by the carrier’s name, address, telephone, and fax number.
Compensation and Medical Lines
The numbered lines capture the full payment history of the claim:
- Line 1 — Date of accident or disability. For occupational disease claims, use the date of disability rather than an injury date.
- Line 2 — Whether salary was continued during the disability period.
- Line 3 — Temporary total disability: weeks, date range, and amount, with a second row available if payments split across periods.
- Line 4 — Temporary partial disability, same structure as Line 3.
- Line 5 — Permanent partial disability: weeks and total paid.
- Line 6 — Disfigurement compensation, if any.
- Line 7 — Benefits paid for the loss or loss of use of a body part.
- Line 8 — The sum of Lines 3 through 7.
- Line 9 — The compromise settlement amount from the approved agreement. This is the figure that distinguishes Form 28C from Form 28B.
- Line 10 — Total medical compensation paid, including hospital bills, physician fees, prescriptions, and related treatment.
Every dollar figure on Lines 3 through 10 should match your records exactly. The Commission treats these numbers as the official closing record for the claim, and discrepancies prompt inquiries that delay final processing. Check that Line 8 reconciles with Lines 3 through 7, and that Line 9 matches the approved agreement on file.
Signature Block
The person signing for the employer or carrier enters their name, title, and the date, then signs. No notarization is required. The section marked “For Industrial Commission Use Only” below the signature stays blank.
Filing Through EDFP and the 16-Day Deadline
Under Rule 11 NCAC 23A .0108, documents filed with the Commission must be submitted electronically through the Electronic Document Filing Portal (EDFP), unless the filer is an unrepresented employee.2North Carolina Industrial Commission. Electronic Document Filing Portal Since employers and carriers file Form 28C, EDFP is effectively mandatory. If the portal is down, you can email the document to edfp@ic.nc.gov as a backup; emails sent while the portal is operational will be rejected.
N.C. Gen. Stat. § 97-18(h) requires Form 28C to reach both the Commission and the employee within 16 days after the final payment of compensation.1North Carolina Industrial Commission. North Carolina General Statute 97-18 – Prompt Payment of Compensation Required The clock runs from the date of the last payment, not the date of the settlement agreement and not the date the check cleared. Serving the worker by a method that creates a delivery record, such as certified mail, protects you if the employee later disputes when notice arrived.
Missing the 16-day window triggers a mandatory $25 civil penalty against the filing party for failing to notify either the Commission or the employee on time.1North Carolina Industrial Commission. North Carolina General Statute 97-18 – Prompt Payment of Compensation Required The dollar figure is modest, but repeated violations build an administrative record that can draw closer scrutiny on later filings.
Serving the Employee and the Two-Year Medical Clock
Filing with the Commission and serving the employee are two distinct obligations under the statute. The Commission receiving the form through EDFP does not count as notice to the worker, and skipping the service step is one of the more common ways carriers fall out of compliance even when the EDFP side is handled on time.
Service matters because Form 28C doubles as the employee’s formal notice that a clock has started on their right to future medical treatment at the employer’s expense. Under N.C. Gen. Stat. § 97-25.1, the right to additional medical compensation ends two years after the employer’s last payment of either medical or indemnity compensation.3North Carolina Industrial Commission. North Carolina General Statute 97-25.1 – Limitation of Duration of Medical Compensation Once that period expires without action, the worker permanently loses the ability to have the employer or carrier pay for further treatment related to the injury.
Two things can prevent the deadline from cutting off benefits. The employee can file an application with the Commission for additional medical compensation before the two years run out, and the Commission approves it. Or the Commission can order additional medical compensation on its own initiative.3North Carolina Industrial Commission. North Carolina General Statute 97-25.1 – Limitation of Duration of Medical Compensation The statute also lets the Commission order ongoing future medical payments if it finds a substantial risk that the worker will need further treatment.4North Carolina General Assembly. Limitation of Duration of Medical Compensation
The prescribed notice language on Form 28C spells out this two-year limitation so the worker cannot later claim they were never told. The filed and served form is the carrier’s record that the required warning was delivered.
Common Mistakes to Avoid
Three errors account for most problems with Form 28C filings. The first is using it on a claim that was not resolved through a compromise settlement, which leaves the statutory notice unsatisfied and can keep the two-year medical window from closing. The second is mismatched dollar figures, where Line 8 does not reconcile with Lines 3 through 7, or Line 9 does not match the approved settlement amount. The third is filing through EDFP but failing to serve the employee separately within the same 16-day window.