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First Benefits Insurance Mutual Claims

Claims Department Phone: 800.360.7867
Fax: 919.977.5844

Claims Reporting

Claims reporting is EASY! Complete a Form 19 within 24 hours of injury (Please review our Guide to Reporting Claims) and fax the form together with an employee report of incident and/or witness statements to (919) 977-5844 or email to Once the Form 19 is completed, provide the injured employee with a copy of the Form 19 and a blank From 18, which is required by law.
Note: Under North Carolina law, employers must report an employee injury within five days of occurrence and knowledge of the injury, but we highly encourage employers to report an injury within 24 hours. Prompt reporting of claims aids in quality investigation, management of medical treatment, and successful return to work, which minimizes claims losses.

Establishing Designated Medical Providers

Under North Carolina law, it is the employer’s right and obligation to direct medical treatment when an employee reports a work-related injury/condition. First Benefits Insurance Mutual can help you locate a medical provider to provide initial treatment to any employee who is injured at work. Don’t wait until an employee is injured and then scramble to locate the best medical provider! We have access to medical networks and can identify a provider if you do not have one you are happy with already.

Claims Forms (All of the NCIC Forms can be found on the North Carolina Industrial Commission website.)

Form 17 – Workers’ Compensation Notice and Instructions to Employers and Employees (Spanish Version)

Form 18 – REQUIRED Notice of Accident to Employer and Claim of Employee, Representative or Dependent for Workers’ Compensation Benefits (Spanish Version) (general instruction sheet)

Form 19 – REQUIRED Employer’s Report of Employee’s Injury or Occupational Disease to the Industrial Commission (Guide to Reporting Claims instruction sheet)

Form 22 – Statement of Days Worked and Earnings of Injured Employee

Form 25P – Itemized Statement of Charges for Drugs

Form 25T – Itemized Statement of Charges for Travel

Questions? Contact us at or call (800) 360-7867.

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