NCSBT Workers' Compensation Fund Member Safety Conference -- Comp In Action
October 1 and 2, 2014
Automobile/Inland Marine Fund
The following forms should be used to notify NCSBT of automobile accidents or losses, inland marine losses, or vehicle schedule changes.
Automobile Loss Notice Form: This form must be completed and submitted to NCSBT promptly following an automobile accident or loss, along with a written statement from the driver of the member vehicle describing the accident or loss and a copy of the police report and any complaint, petition or other pleading filed in court as a result of the accident or loss.
Inland Marine Loss Notice Form: This form must be completed and submitted to NCSBT promptly, or in any event within fifteen (15) days of discovery of the loss. Please also attach a copy of any incident report prepared, and a copy of the receipt, purchase order, or invoice for the covered property.
Vehicle Change Request Form: This form must be completed to make an addition, deletion, or change to your vehicle schedule.
Errors & Omissions/General Liability Fund—Medical Payments Coverage
The following instructions and forms are to be used when filing a claim or submitting information related to a claim under NCSBT’s no-fault medical expenses coverage.
How To File A Claim: This instruction sheet explains how to file a claim for NCSBT’s no-fault medical expenses coverage.
Medical Expense Certificate: This Medical Expense Certificate, along with all requested documentation, must be completed and submitted to NCSBT within one year of an accidental injury.
Supplement to Medical Expense Certificate: This Supplement to the Medical Expense Certificate, along with all requested documentation, may be completed and submitted to NCSBT within fourteen (14) months of an accidental injury. However, it should only be used to supplement a Medical Expense Certificate which has been previously completed and provided to the Superintendent or his or her designee and which has been timely filed with NCSBT within one year of an accidental injury.