nc workers comp form 22 is the North Carolina wage form for a workers’ comp claim. Your employer fills it out to show the days you worked and the money you earned before you got hurt. The form’s full name is the Statement of Days Worked and Earnings of Injured Employee. It goes to the North Carolina Industrial Commission. Your weekly check is based on these numbers, so it helps to understand this form even though you don’t file it yourself.
What the Nc Workers Comp Form 22 Is For
When a work injury keeps you off the job, North Carolina generally pays a share of your lost wages. To work out that share, the state needs your average weekly wage. The nc workers comp form 22 gives the raw facts behind that number. It shows how many days you worked and how much you were paid for that work during the period before the injury.
In most cases, the form looks back over roughly the year before you got hurt. It can include regular pay, overtime, and other earnings. However, if you worked there only a short time, the math may be done another way. The rules for those cases are detailed. As a result, it is smart to confirm with the Commission how your wage should be counted.
| Item | Details |
|---|---|
| Form number | Form 22 |
| Form title | Statement of Days Worked and Earnings of Injured Employee |
| Who files | the employer |
| Where filed | North Carolina Industrial Commission |
| Fee | No fee is listed on the form; confirm with the Commission |
| Official PDF | Form 22 official PDF |
Who Files the Nc Workers Comp Form 22 and When
The employer files the nc workers comp form 22, not the injured worker. Typically, the employer or its insurance carrier pulls the numbers from payroll records. Then the form goes to the Commission and the carrier. You do not need to fill it out. However, you have every right to see it and check the figures.
The form is usually tied to the start of benefits. For example, it often comes into play when the carrier begins paying weekly checks. It can also be requested later if your wage is in dispute. If you are still learning the basics, our guide on how to file a North Carolina workers comp claim explains the first steps.
If your checks started and you never saw this form, that is not unusual. Many workers never see it. You can ask the carrier or your employer for a copy. You can also ask the Commission for help if no one responds.
How to Fill It Out and Where to Send It
The nc workers comp form 22 asks for basic claim details first. These include your name, the employer, the carrier, and the date of injury. Next comes the wage section. It typically lists each pay period, the days worked, and the gross earnings. The employer signs the form to confirm the numbers are true.
Common mistakes can lower your weekly check. Watch for these problems:
- Missing overtime or bonus pay
- Leaving out weeks you actually worked
- Counting days off as days worked, which spreads your pay too thin
- Leaving out pay from a second job with the same employer
- Wrong date of injury or claim number
Forms with missing details may be sent back or questioned. As a result, benefits can be delayed. The employer can usually file through the Commission’s electronic filing system or by mail. You can get the blank form from the official North Carolina Industrial Commission forms page. The direct link is the official Form 22 PDF. Always use the current version from the Commission.
What Happens After You File
Once the nc workers comp form 22 is in, the carrier uses it to set your average weekly wage. Your weekly benefit is then based on a share of that wage, up to the state’s yearly cap. The Commission sets that cap each year, so confirm the current figure with the Commission. If the wage looks too low, you can raise a dispute. In most cases, you start by asking the carrier to correct it. If that fails, you can ask the Commission to decide.
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To learn more about the agency, read our guide to the North Carolina workers comp board. You can also review North Carolina workers comp requirements to see what employers must do. Any settlement estimate you hear is only illustrative. Every case is different. Confirm your figures with the Commission and a licensed attorney before acting.
Frequently Asked Questions
Do I have to fill out the nc workers comp form 22 myself?
No. The employer fills out and files the nc workers comp form 22. However, you can ask for a copy and check it against your own pay stubs.
What if my wages on Form 22 are wrong?
Gather your pay stubs, tax forms, or bank records first. Then ask the carrier in writing to fix the numbers. If they will not, you may ask the North Carolina Industrial Commission to review the wage dispute.
Does the nc workers comp form 22 affect how much I get paid?
Yes, it can. Your weekly benefit is typically based on your average weekly wage, and this form supplies the numbers behind it. A small error on the nc workers comp form 22 can change every check, so it is worth a careful look.
Nc workers comp form 22: Quick Recap
If you remember one thing about nc workers comp form 22, make it this: the rule is set by the state (or the federal program), not by the insurer, and the official source is linked above. Every figure on this page about nc workers comp form 22 should be confirmed with the agency before you act on it.
Questions about nc workers comp form 22 that this page does not answer are usually answered for free by the state workers’ comp agency’s information line — and, for a disputed claim, by a licensed attorney in a first consultation.
See your state’s exact numbers
What you are owed depends on your state’s benefit caps and deadlines. Start with your state’s settlement and claim guides for the exact figures.
Sources & How to Verify
The figures on this page come from official government and industry sources. Workers’ comp benefit caps, deadlines, and rules change, so always confirm the exact figure with your state’s workers’ comp board or a licensed attorney before acting. Settlement estimates are illustrative, and every case is different.
- Your state workers’ comp board, division, or commission: the official source for your state’s exact caps, deadlines, and forms — search “[your state] workers compensation board”
- U.S. Department of Labor (OWCP): dol.gov — federal workers’ compensation overview
- NCCI: ncci.com — workers’ comp rating and benefit data
- Social Security Administration: ssa.gov — benefit-cap and SSDI offset data
- Insurance Information Institute: iii.org — neutral workers’ comp background
Content last reviewed October 2026. If you notice an outdated figure, please contact us.
Related Guides
- North Carolina Workers Comp Board
- How to File a North Carolina Workers Comp Claim
- North Carolina Workers Comp Requirements
- Workers Comp Settlements by State (All 50)
- Workers Comp Claims by State (All 50)
- More in This Category
- Settlements by Injury
- Benefits Explained
- Workers Comp Glossary
Informational only — not legal, medical, or financial advice. Workers Comp Explained is an independent educational resource, not a law firm, insurer, or medical or financial advisor, and this page does not provide legal, medical, or financial advice. Workers’ compensation benefits, deadlines, and rules vary by state and change over time, and settlement estimates are illustrative only. Always confirm the exact figure and any deadline with your state’s workers’ compensation board and a licensed attorney before you act.