The North Carolina Industrial Commission’s Form 21 is the Agreement for Compensation for Disability. This is the form that will be generated after an agreement for payment has been reached with your employer if you have reached a settlement with your employer but need to keep your claim open in case you need further treatment.

Form 21 details the agreement you have reached with your employer and gives you the opportunity to pursue further compensation at a later date; however, there are certain deadlines under which you have to file a claim for further compensation.

The Form 21 is to be completed and must be signed by both the employee and the employer. On the form you will detail the date and nature of the injuries received, your average pay at the time of the accident, and the agreed upon amount and structure for payments to the employee.

Once your agreed-upon compensation checks have stopped, you have two years to file a claim for further compensation from your employer. If more than two years have passed since you received your last compensation check, any claim to further benefits may be lost.