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The North Carolina 90 form, also known as the Report of Earnings, plays a crucial role in the administration of workers' compensation benefits in the state. This form is mandated by the North Carolina Workers' Compensation Act and is essential for both employees and employers. It serves as a tool for employees receiving workers' compensation benefits to report any earnings they may have during a specified time period. The form requires detailed information, including the employee's personal details, employer information, and any earnings from other employment or self-employment. Employees must fill out the second page of the form, indicating whether they received any earnings and providing specifics if they did. Timeliness is critical; employees are required to return the completed form within 15 days of receipt. Failure to do so can result in the suspension of benefits. Additionally, the form emphasizes the importance of accurately reporting earnings, as any false statements can lead to civil and criminal penalties. This document not only ensures compliance with the law but also protects the rights of both employees and employers in the workers' compensation system.
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NORTH CAROLINA INDUSTRIAL COMMISSION
IC File #
REPORT OF EARNINGS
Emp. Code #
Carrier Code #
Carrier File #
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Employer FEIN
(EMPLOYER/INSURANCE CARRIER TO COMPLETE THIS SECTION)
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To Employees: The Employer/Insurance Carrier periodically needs to verify your continuing eligibility for workers' compensation benefits and to update their records. You are required to complete Page 2 of this Report of Earnings and return it to the insurer or employer address provided on page 2 of this form within 15 days after receipt of this form, even if you have no earnings.
**YOUR WORKERS' COMPENSATION BENEFITS MAY BE SUSPENDED IF YOU FAIL
TO COMPLETE THIS REPORT IN A TIMELY MANNER.**
NOTICE TO EMPLOYEES RECEIVING WORKERS' COMPENSATION
When you are receiving weekly workers' compensation benefits, YOU MUST REPORT ANY EARNINGS YOU RECEIVE TO THE INSURANCE CARRIER (OR EMPLOYER IF THE EMPLOYER IS
You must report any work in any business, even if the business lost money or if profits or income were reinvested or paid to others.
Your endorsement on a benefit check or deposit of the check into an account is your statement that you are entitled to receive workers' compensation benefits. Your signature on a benefit check is a further affirmation that you have made no false claims or statements or concealed any material fact regarding your right to receive workers' compensation benefits.
MAKING FALSE STATEMENTS FOR THE PURPOSE OF OBTAINING WORKERS' COMPENSATION BENEFITS
MAY RESULT IN CIVIL AND CRIMINAL PENALTIES.
TIME PERIOD COVERED BY THIS REPORT: ___________________ to _____________________
(Employer/Insurance Carrier must complete)
FORM 90 2/01
PAGE 1 OF 2
FORM 90
NORTH CAROLINA INDUSTRIAL COMMISSION
4340 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA
MAIN TELEPHONE: (919)
HELPLINE: (800)
WEBSITE: HTTP://WWW.IC.NC.GOV/
EMPLOYEE: COMPLETE SECTION BELOW
(1) Did you receive earnings from work during the time period
indicated on Page 1? |
YES |
NO |
(2) Did you work for a business or any person during that time
period? |
YES |
NO |
(3)If you answered NO to both questions 1 and 2, sign and return the form to the insurance carrier or to the individual identified by the insurance carrier or employer listed below.
(4)If you answer YES to either question, complete item 5 below, sign and return the form to the insurance carrier or to the individual identified by the insurance carrier or employer listed below. For the purposes of this statement, “Gross Earnings” include all
(5)1st Employer or Business Name (include
Location:
Dates worked:
Gross Earnings:
Next Employer or Business Name (include
Location:
Dates worked:
Gross Earnings:
Attach additional page(s) if necessary.
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(Required)
NOTICE TO EMPLOYEE:
1.Failure to report earnings as defined herein may subject you to criminal prosecution and civil liability including the suspension or forfeiture of your benefits. This form must be signed and returned to the insurance carrier listed below even if you have no earnings.
2.If the Commission suspends benefits for failure to complete and return a Form 90 Report of Earnings, the
3.If benefits are not immediately reinstated, the employee should submit a written request for an Order from the Executive Secretary instructing the employer or insurance carrier to reinstate benefits. An application for reinstatement of benefits should be addressed to North Carolina Industrial Commission, Office of the Executive Secretary, 4333 Mail Service Center, Raleigh, NC
Insurance carrier or Employer must list the name and address below of the person to whom this form must be returned and mail this form to the employee by certified mail return receipt requested, and include a
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NOTICE TO INSURER OR EMPLOYER:
Any person who willfully makes a false statement or representation of a material fact for the purpose of denying or assisting another in denying any benefit or payment under the Workers’ Compensation Act shall be guilty of a Class 1 misdemeanor if the amount at issue is less than $1000. Violation is a Class H felony if the amount at issue exceeds $1000. Any person who threatens an employee with criminal prosecution under the provisions of the Act for the purpose of coercing or attempting to coerce an employee into agreeing to compensation under the Act shall be guilty of a Class H felony.
FORM 90 2/01
PAGE 2 OF 2
FORM 90
NORTH CAROLINA INDUSTRIAL COMMISSION
4340 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA
MAIN TELEPHONE: (919)
HELPLINE: (800)
WEBSITE: HTTP://WWW.IC.NC.GOV/
Form Specifications
| Fact Name | Details |
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| Form Title | NORTH CAROLINA INDUSTRIAL COMMISSION IC File # REPORT OF EARNINGS |
| Governing Law | This form is required under the provisions of the Workers' Compensation Act. |
| Employer Information | The employer or insurance carrier must complete the employer's name, address, and FEIN. |
| Employee Requirements | Employees must report any earnings to the insurance carrier or employer within 15 days. |
| Consequences of Non-Compliance | Failure to complete the report may result in suspension of workers' compensation benefits. |
| Definition of Earnings | Earnings include wages, commissions, bonuses, and any non-cash payments received. |
| False Statements | Making false statements can lead to civil and criminal penalties. |
| Submission Process | The completed form must be signed and returned to the designated insurance carrier. |
| Reinstatement of Benefits | Benefits must be reinstated upon submission of the report, with back payment if applicable. |
North Carolina 90: Usage Guidelines
The North Carolina 90 form is essential for employees receiving workers' compensation benefits. Completing it accurately and promptly is crucial to ensure that benefits are not suspended. Follow these steps carefully to fill out the form correctly.
- Begin by locating the top section of the form. Fill in the IC File #, Emp. Code #, Carrier Code #, and Carrier File # as required.
- In the section labeled Employer FEIN, provide the Federal Employer Identification Number.
- Next, enter your Employee’s Name, Address, City, State, and Zip code in the designated fields.
- Fill in your Home Telephone and Work Telephone numbers.
- Indicate your Sex by checking the appropriate box for either M (Male) or F (Female).
- Provide your Date of Birth in the format requested.
- Enter your Social Security Number in the specified area.
- Next, fill out the Employer's Name, Telephone Number, and Address, including City, State, and Zip.
- Provide the Insurance Carrier name and its Address, including City, State, and Zip.
- Fill in the Carrier's Telephone Number and Fax Number.
- In the section for Time Period Covered by this Report, write the start and end dates of the reporting period.
- On Page 2, answer questions (1) and (2) by checking YES or NO as applicable.
- If you answered NO to both questions, sign and return the form as instructed.
- If you answered YES to either question, proceed to item (5).
- In item (5), list your first employer or business name, location, dates worked, and gross earnings. Repeat for any additional employers or businesses.
- Sign and date the form at the bottom where indicated.
Once you have completed the form, ensure that it is returned to the insurance carrier or employer as instructed. Timely submission is essential to maintain your benefits.
Your Questions, Answered
What is the North Carolina 90 Form?
The North Carolina 90 Form, also known as the Report of Earnings, is a document required under the Workers' Compensation Act. It is used by employers and insurance carriers to verify an employee's ongoing eligibility for workers' compensation benefits. The form must be completed by the employee and returned to the employer or insurance carrier within 15 days of receipt, even if the employee has no earnings to report.
Who needs to fill out the North Carolina 90 Form?
Employees who are receiving workers' compensation benefits must complete the North Carolina 90 Form. This includes any employee who has had a work-related injury and is currently receiving benefits. The form is also relevant for employers and insurance carriers who need to maintain accurate records regarding the employee's earnings and eligibility for benefits.
What happens if I do not return the North Carolina 90 Form on time?
If the North Carolina 90 Form is not completed and returned within the required 15-day period, the employee's workers' compensation benefits may be suspended. It is crucial to adhere to this timeline to ensure that benefits continue without interruption. Failure to report earnings can also lead to civil and criminal penalties.
What information do I need to provide on the North Carolina 90 Form?
The form requires various pieces of information, including the employee's name, address, Social Security number, and details about any earnings received during the specified time period. Employees must report any income from self-employment or other jobs, including bonuses and commissions. If there are multiple employers, the employee should provide information for each one.
What should I do if I have no earnings to report?
If you have not received any earnings during the specified time period, you still need to fill out the form. You can indicate that you have no earnings by answering "NO" to the relevant questions on the form. After signing, return the form to the employer or insurance carrier as instructed.
What are the consequences of making false statements on the North Carolina 90 Form?
Making false statements or misrepresenting information on the North Carolina 90 Form can result in serious consequences. This includes civil liability and criminal penalties. If the falsehood involves an amount under $1,000, it is classified as a Class 1 misdemeanor. If the amount exceeds $1,000, it can be considered a Class H felony. It is essential to provide accurate and truthful information to avoid these penalties.
Common mistakes
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Failing to report all earnings accurately. Many individuals underestimate the importance of disclosing every source of income, including bonuses and commissions. All earnings must be reported, regardless of how small they may seem.
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Not completing the form within the required 15-day timeframe. Timeliness is crucial. If the form is not returned promptly, workers' compensation benefits may be suspended.
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Ignoring the requirement to report self-employment earnings. Some people believe that if their business is not profitable, they do not need to report it. This is incorrect; all self-employment income must be disclosed.
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Overlooking the necessity of signing the form. A signature is required to validate the report. Failing to sign can lead to delays in processing and potential issues with benefits.
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Misunderstanding what constitutes "earnings." Individuals sometimes think that only wages from their primary job count, but all forms of compensation, including non-cash benefits, must be reported.
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Not keeping copies of submitted forms. It is wise to retain a copy for personal records. This can help in case of disputes or questions regarding the information provided.
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Failing to read the instructions thoroughly. The form contains critical information about what needs to be reported. Skimming through the instructions can lead to mistakes.
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Assuming that previous earnings do not need to be reported if they were earned before the injury. This is a common misconception. All earnings during the specified time period must be reported, regardless of when they were earned.
Documents used along the form
The North Carolina 90 form is a crucial document for employees receiving workers' compensation benefits. It helps verify ongoing eligibility and ensures that all earnings are accurately reported. Alongside this form, several other documents may be necessary to complete the workers' compensation process effectively. Below is a list of commonly used forms and documents.
- Form 18: This form is used to report an employee's injury to the North Carolina Industrial Commission. It provides essential details about the incident and initiates the claims process.
- Form 19: The Employer's Report of Injury, or Form 19, is completed by the employer to notify the Industrial Commission of an employee's injury. This form outlines the circumstances surrounding the incident and any benefits the employer intends to provide.
- Form 21: The Agreement for Compensation is used when the employer and employee agree on the amount of compensation for the injury. This form must be approved by the Industrial Commission.
- Form 26: This is the Employee's Request for Hearing. If there is a dispute regarding benefits, this form allows the employee to request a hearing before the Industrial Commission.
- Form 30: The Application for Approval of Settlement is used when parties agree to settle a workers' compensation claim. This form must be submitted for approval to ensure compliance with the law.
- Form 33: This form is the Request for Hearing and is used to initiate a hearing on a disputed claim. It details the issues at stake and the relief sought by the employee.
- Form 60: The Employer's Admission of Employee's Right to Compensation is a form used by the employer to admit liability for the employee's injury and to outline the benefits to be provided.
- Form 63: This is the Employer's Response to Employee's Claim. It is used to inform the Industrial Commission of the employer's position regarding the claim and any defenses they may have.
- Form 90: As mentioned, this form is essential for reporting earnings during the period of receiving benefits. Timely submission is critical to avoid suspension of benefits.
Understanding these documents is vital for both employees and employers involved in the workers' compensation process in North Carolina. Each form serves a specific purpose, ensuring compliance with legal requirements and facilitating the efficient management of claims. Prompt attention to these documents can prevent delays and complications in receiving benefits.
Similar forms
The North Carolina 90 form serves a crucial role in the workers' compensation process. It is similar to several other documents that also aim to track earnings and ensure compliance with reporting requirements. Below is a list of nine documents that share similarities with the North Carolina 90 form:
- Workers' Compensation Claim Form: This form initiates the workers' compensation process, detailing the injury and the employee's information, much like the North Carolina 90 form gathers essential data about earnings.
- Employee Earnings Report: Similar in purpose, this report requires employees to disclose their earnings during a specific period, just as the North Carolina 90 form does.
- Return to Work Form: This document outlines an employee's readiness to return to work after an injury, paralleling the North Carolina 90's focus on verifying ongoing eligibility for benefits.
- Benefit Verification Form: This form is used to confirm an employee's current benefits status, similar to how the North Carolina 90 form seeks to update records regarding earnings.
- Self-Employment Earnings Report: This document specifically addresses earnings from self-employment, akin to the North Carolina 90 form's requirement to report all sources of income.
- Disability Status Update Form: This form provides updates on an employee's disability status, which is relevant to the ongoing assessment of benefits, much like the North Carolina 90 form.
- Claimant's Statement of Earnings: This statement requires claimants to provide detailed information about their earnings, paralleling the requirements of the North Carolina 90 form.
- Medical Release Form: While primarily focused on medical information, this form often accompanies earnings reports to ensure that the employee's condition aligns with their reported earnings.
- Final Settlement Agreement: This document outlines the terms of a final settlement in a workers' compensation case, which may reference earnings and benefits similar to the North Carolina 90 form's intent.
Dos and Don'ts
When filling out the North Carolina 90 form, it is crucial to follow specific guidelines to ensure compliance and avoid potential issues. Here are six things to do and not do:
- Do complete all required sections accurately, including your personal information and employment details.
- Do report any earnings you received during the specified time period, even if they are from self-employment or other jobs.
- Do return the completed form within 15 days of receipt to avoid suspension of benefits.
- Do sign and date the form to affirm that the information provided is true and complete.
- Don't ignore the requirement to report earnings, as failing to do so can lead to criminal prosecution and loss of benefits.
- Don't provide false information or omit details, as this could result in serious legal consequences.
By adhering to these guidelines, individuals can ensure that their submissions are processed smoothly and that they remain compliant with the Workers' Compensation Act.
Misconceptions
- Misconception 1: The North Carolina 90 form is only for employees who have earnings.
- Misconception 2: Reporting earnings on the North Carolina 90 form is optional.
- Misconception 3: Only cash payments need to be reported.
- Misconception 4: The North Carolina 90 form is a one-time requirement.
This is incorrect. All employees receiving workers' compensation benefits must complete and return the form, even if they have no earnings during the specified period. Failing to do so may result in the suspension of benefits.
In reality, it is mandatory for employees to report any earnings received while on workers' compensation. This includes any income from self-employment or other jobs. Not reporting earnings can lead to serious penalties.
This is misleading. The form requires reporting of all forms of earnings, including non-cash benefits such as housing allowances or bonuses. Any compensation received must be disclosed, regardless of its form.
In fact, employees must complete this form periodically as requested by their employer or insurance carrier. Regular updates are necessary to maintain eligibility for benefits.
Key takeaways
When dealing with the North Carolina 90 form, understanding its purpose and requirements is crucial for both employees and employers. Here are some key takeaways to consider:
- Timely Submission is Essential: Employees must complete and return the form within 15 days of receipt. Failure to do so may result in suspension of workers' compensation benefits.
- Report All Earnings: Any earnings from work, including self-employment or other jobs, must be reported. This includes wages, bonuses, and even non-cash benefits.
- False Statements Have Consequences: Making false claims on this form can lead to civil and criminal penalties. Honesty is paramount when reporting earnings.
- Reinstatement of Benefits: If benefits are suspended due to non-completion of the form, they must be reinstated promptly upon submission of the completed report.
Understanding these points can help ensure compliance and protect workers' rights while navigating the workers' compensation process in North Carolina.