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South Carolina Workers’ Compensation Forms

  • Form #5 – Corporate Officer Notice to Reject
  • Form #6 – Application to Create a Self-Insurance Fund – $250.oo
  • Form #6A – Application for Membership in a Self-Insurance Fund – $25.00
  • Form #7 – Application to Individually Self-Insure $250.00
  • Form #7A – Corporate Guaranty
  • Form #8 – SC Workers’ Compensation Commission Bond Required of Employer Carrying His Own Risk
  • Form #8B – Irrevocable Letter of Credit
  • Form #10 – South Carolina Self-Insurance Tax Form
  • Form #11 – Fund Quarterly Financial Report
  • Form #12A – First Report of Injury
  • Form #12M – Annual Minor Medical Report
  • Form #14B – Physician’s Statement
  • Form #15 – Temporary Compensation Report
  • Form #15S – Supplemental Report of Varying Temporary Partial Payments
  • Form #16 – Agreement for Permanent Disability / Disfigurement Compensation
  • Form #16A – Agreement for Permanent Disability / Disfigurement Compensation. Please complete this form for injuries occurring after July 1, 2007.
  • Form #17 – Receipt of Compensation
  • Form #18 – Periodic Report
  • Form #19 – Status Report and Compensation Receipt
  • Form #20 – Statement of Earning of Injured Employee
  • Form #21 – Employer’s Request for Hearing
  • Form #22 – Claimant’s Answer to Request for Hearing
  • Form #24 – Application for Lump Sum Award
  • Form #27 – Subpoena
  • Form #30 – Request for Commission Review
  • Form #32 – Request to Waive Appeal Filing Fee
  • Form #33 – Hearing Postponed
  • Form #38 – Employer’s Withdrawal of Election to Adopt the South Carolina Workers’ Compensation Act
  • Form #39 – Coverage Coding Sheet
  • Form #50 – Employee’s Notice of Claim and or Request for Hearing
  • Form #51 – Employer’s Answer to Request for Hearing
  • Form #52 – Employee’s Notice of Claim and/or Request for Hearing
  • Form #53 – Employer’s Answer to Request for Hearing, Death Case
  • Form #54 – Employer’s Notice of Claim and/or Request for Hearing
  • Form #55 – Second Injury Fund’s Answer to Employee’s Request for Hearing
  • Form #58 – Pre-Hearing Brief
  • Form #59 – Appellant’s Informal Brief
  • Form #61 – Attorney Fee Petition
  • Form #61 Order – Attorney Fee Petition
  • Form #61A – Attorney Fee Petition Supplemental Information
  • Form #65 – Occupational Disease Waiver
  • Form #70 – Mediator Report
  • Form #S-1 – Notice of Third Party Action Employee Carrier
  • Form #S-2 – Notice of Third Party Action Employee
  • Form #S-3 – Entitlement to Right of Action
  • Form #S-4 – Court Certificate

Self-Insurance Forms

  • Form #6 – Application to Create a Self-Insurance Fund
  • Form #6A – Application for Membership in a Self-Insured Fund
  • Form #7 – Application to Individually Self-Insure
  • Form #7A – Corporate Guaranty
  • Form #8 – SC Workers’ Com. Comm. Bond Required of Employer Carrying His On Risk
  • Form #8B – Irrevocable Letter of Credit
  • Form #10 – South CarolinaSelf-Insurance Tax Form (for calculations, Java scripting must be enabled in Adobe Reader)
  • Form #11 – Fund Quarterly Financial Report

Claims Forms

  • Form #12A – First Report of Injury
  • Form #12M – Annual Minor Medical Report
  • Form #14B – Physician’s Statement
  • Form #15 – Temporary Compensation Report
  • Form #15S – Supplemental Report of Varying Temporary Partial Payments
  • Form #16 – Agreement for Permanent Disability/Disfigurement Compensation
  • Form #16A – Agreement for Permanent Disability/Disfigurement Compensation. Please complete this form for injuries occurring after July 1, 2007
  • Form #17 – Receipt of Compensation
  • Form #18 – Periodic Report
  • Form #19 – Saturation Report and Compensation Report
  • Form #20 – Statement of Earnings of Injured Employee
  • Form #24 – Application for Lump Sum Award
  • Form #50 – Employee’s Notice of Claim and or Request for Hearing
  • Form #52 – Employee’s Notice of Claim and/or Request for Hearing
  • Form #61 – Attorney Fee Petition
  • Form #S-1 – Notice of Third Party Action Employee Carrier
  • Form #S-2 – Notice of Third Party Action Employee

Judicial Forms

  • Form #21 – Employer’s Request for Hearing
  • Form #22 – Claimant’s Answer to Request for Hearing
  • Form #27 – Subpeana
  • Form #30 – Request for Commission Review
  • Form #32 – Request to Waive Appeal Filing Fee
  • Form #33 – Hearing Postponed
  • Form #51 – Employer’s Answer to Request for Hearing
  • Form #53 – Employer’s Answer to Request for Hearing, Death, Case
  • Form #54 – Employer’s Notice of Claim and/or Request for Hearing
  • Form #55 – Second Injury Fund’s Answer to Employee’s Request for Hearing
  • Form #58 – Pre-Hearing Brief
  • Form #59 – Appellant’s Informational Brief
  • Form #65 – Occupational Disease Waiver
  • Form #70 – Mediator Report