Transcription of Itemized Statement of Charges for Travel - N.C. Industrial ...
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Itemized Statement of Charges for Travel - N.C. Industrial ...
FORM 25T 12/2017 PAGE 1 OF 1 NOTICE TO INJURED EMPLOYEE: THIS FORM SHOULD BE RETURNED TO THE CARRIER AT THE ADDRESS ABOVE FOR PAYMENT. FOR ASSISTANCE, CALL: Industrial commission MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 FORM 25T North Carolina Industrial commission IC File # Itemized Statement OF Charges FOR Travel Emp. Code # Carrier Code #The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Carrier File #Employer FEIN () -Employee s Name Employer's Name Telephone Number Address Employer s Address City State Zip City State
FORM 25T 01/2021 PAGE 1 OF 1 N.C. H NOTICE TO INJURED EMPLOYEE: THIS FORM SHOULD BE RETURNED TO THE CARRIER AT THE ADDRESS ABOVE FOR PAYMENT. FOR ASSISTANCE, CALL: INDUSTRIAL COMMISSION MAIN TELEPHONE: (919) 807-2500 ELPLINE: (800) 688-8349 FORM 25T North Carolina Industrial Commission IC File # ITEMIZED STATEMENT OF CHARGES …
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