Forms and Publications

North Carolina

Statement of Injured
Please complete this form with the details of your injury and return it to Summit.

Medical Release
You must sign this form, have it witnessed and return it to Summit in order for us to process your compensation.

Notice of Accident to Employer and Claims of Employee, Representative, or Dependent
To make a claim, you must complete, sign and submit this form to the North Carolina Industrial Commission within two years of the date of your injury or last payment of medical compensation. Mail this form to:
NCIC - Claims Administration
4335 Mail Service Center
Raleigh, NC 27699-4335

Itemized Statement of Charges for Travel   
Use this form to submit a request for mileage reimbursement.

Itemized Statement of Charges for Drugs
Use this form to submit a request for prescription drug reimbursement.

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