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Fighting for South Carolina Injury Victims for Over 50 Years

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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