Revised NCIC Form 17

Document created by 1002043 on Nov 20, 2014Last modified by 1002043 on Mar 10, 2017
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The North Carolina Industrial Commission has released the agency’s revised Form 17; “N.C. Workers’ Compensation Notice To Injured Workers and Employers”.  This is the form that is required to be prominently posted by North Carolina employers.  One of the major differences in this form (11/14) from the previous one (5/10) is the specific information required to be filled in by the employer, such as the following:


  • Your employer’s workers’ compensation insurance company is_________________.
  • The insurance policy number is____________________________________________.
  • Your employer’s workers’ compensation insurance policy is valid from ________until_______.


The English and Spanish versions are available in myCAI by clicking on the Find CAI Resources tab and then on the Required Posters page link..  The English version will be included in CAI’s new combined Employment Law Poster that we plan sending out to our members in February 2015.  CAI will also be revising the OSHA section due to new employer responsibilities effective January 1, 2015.


If you have any questions about the new NCIC Form 17 or any other required posters, call CAI’s Advice and Resolution Team at 919-878-9222 or 336-668-7746.