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The South Carolina Workers' Compensation Commission offers all of its forms in Word format so that they can be completed and calculated (where applicable), as well as in PDF format so that they can be printed out and completed manually.

If you need assistance with any of these forms, please contact the Commission. All forms have a direct phone number listed for assistance.

Form #	Name	Download	Filing Fee
Form 5	Corporate Officer Notice to Reject	Word PDF	No fee
Form 6	Application to Create a Self-Insurance Fund	Word PDF	$250.00
Form 6A	Application for Membership in a Self-Insured Fund	Word PDF	$25.00
Form 7	Application to Individually Self-Insure	Word PDF	$250.00 plus $100.00 for each subsidiary
Form 7A	Corporate Guaranty	Word PDF	No fee
Form 8	SC Workers’ Com. Comm. Bond Required of Employer Carrying His On Risk	Word PDF	No fee
Form 8B	Irrevocable Letter of Credit	Word PDF	No fee
Form 10	South Carolina Self-Insurance Tax Form	Word PDF	No fee
Form 11	Fund Quarterly Financial Report	Word PDF	No fee
Form 12A	First Report of Injury	Word PDF	No fee
Form 12M	Annual Minor Medical Report	Word PDF	No fee
Form 14A	Health Insurance Claim Form	PDF	No fee
Form 14B	Physician’s Statement	Word PDF	No fee
Form 15	Temporary Compensation Report	Word PDF	$25.00 for Section III only
Form 15S	Supplemental Report of Varying Temporary Partial Payments	Word PDF	No fee
Form 16	Agreement for Permanent Disability/ Disfigurement Compensation	Word PDF	$25.00 if Claimant is represented
Form 16A	Agreement for Permanent Disability/ Disfigurement Compensation Please complete this form for injuries occurring after July 1, 2007.	Word PDF	$25.00 if Claimant is represented
Form 17	Receipt of Compensation	Word PDF	No fee
Form 18	Periodic Report	Word PDF	No fee
Form 19	Status Report and Compensation Receipt	Word PDF	No fee
Form 20	Statement of Earning of Injured Employee	Word PDF	No fee
Form 21	Employer's Request for Hearing	Word PDF	$25.00
Form 24	Application for Lump Sum Award	Word PDF	$25.00
Form 27	Subpoena	Word PDF	No fee
Form 30	Request for Commission Review	Word PDF	$150.00
Form 32	Request to Waive Appeal Filing Fee	Word PDF	No fee
Form 33	Hearing Postponed	Word PDF	No fee
Form 38	Employer’s Withdrawal of Election to Adopt the South Carolina Workers’ Compensation Act	Word PDF	No fee
Form 40	Motion for Expedited Adjudication	Word PDF	$25.00
Form 50	Employee's Notice of Claim and or Request for Hearing	Word PDF	$25.00 for Request for Hearing only
Form 51	Employer's Answer to Request for Hearing	Word PDF	No fee
Form 52	Employee's Notice of Claim and/or Request for Hearing	Word	$25.00 for Request for Hearing only
Form 53	Employer's Answer to Request for Hearing, Death Case	Word PDF	No fee
Form 54	Employer's Notice of Claim and/or Request for Hearing	Word PDF	$25.00
Form 55	Second Injury Fund's Answer to Employee's Request for Hearing	Word PDF	No fee
Form 58	Pre-Hearing Brief	Word PDF	No fee
Form 59	Appellant’s Informal Brief	Word PDF	No fee
Form 61	Attorney Fee Petition	Word PDF	No fee
61 Order	Attorney Fee Petition	Word PDF	No fee
Form 65	Occupational Disease Waiver	Word PDF	No fee
N/A	Coverage Coding sheet for Attorneys	Word PDF	No fee
Form S-1	Notice of Third Party Action Employee Carrier	Word PDF	No fee
Form S-2	Notice of Third Party Action Employee	Word PDF	No fee
Form S-3	Entitlement to Right of Action	Word PDF	No fee
Form S-4	Court Certificate	Word PDF	No fee

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Self-Insurance Forms

Form 6	Application to Create a Self-Insurance Fund	Word PDF	$250.00
Form 6A	Application for Membership in a Self-Insured Fund	Word PDF	$25.00
Form 7	Application to Individually Self-Insure	Word PDF	$250.00 plus $100.00 for each subsidiary
Form 7A	Corporate Guaranty	Word PDF	No fee
Form 8	SC Workers’ Com. Comm. Bond Required of Employer Carrying His On Risk	Word PDF	No fee
Form 8B	Irrevocable Letter of Credit	Word PDF	No fee
Form 10	South Carolina Self-Insurance Tax Form	Word PDF	No fee
Form 11	Fund Quarterly Financial Report	Word PDF	No fee

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Claims Forms

Form 12A	First Report of Injury	Word PDF	No fee
Form 12M	Annual Minor Medical Report	Word PDF	No fee
Form 14A	Health Insurance Claim Form	PDF	No fee
Form 14B	Physician’s Statement	Word PDF	No fee
Form 15	Temporary Compensation Report	Word PDF	$25.00 for Section III only
Form 15S	Supplemental Report of Varying Temporary Partial Payments	Word PDF	No fee
Form 16	Agreement for Permanent Disability Disfigurement Compensation	Word PDF	$25.00 if filed by Claimant's Attorney
Form 16A	Agreement for Permanent Disability/ Disfigurement Compensation Please complete this form for injuries occurring after July 1, 2007.	Word PDF	$25.00 if filed by Claimant's Attorney
Form 17	Receipt of Compensation	Word PDF	No fee
Form 18	Periodic Report	Word PDF	No fee
Form 19	Status Report and Compensation Receipt	Word PDF	No fee
Form 20	Statement of Earning of Injured Employee	Word PDF	No fee
Form 24	Application for Lump Sum Award	Word PDF	$25.00
Form 50	Employee's Notice of Claim and or Request for Hearing	Word PDF	$25.00 for Request for Hearing only
Form 52	Employee's Notice of Claim and/or Request for Hearing	Word PDF	$25.00 for Request for Hearing only
Form 61	Attorney Fee Petition	Word PDF	No fee
Form S-1	Notice of Third Party Action Employee Carrier	Word PDF	No fee
Form S-2	Notice of Third Party Action Employee	Word PDF	No fee

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Judicial Forms

Form 21	Employer's Request for Hearing	Word PDF	$25.00
Form 27	Subpoena	Word PDF	No fee
Form 30	Request for Commission Review	Word PDF	$150.00
Form 32	Request to Waive Appeal Filing Fee	Word PDF	No fee
Form 33	Hearing Postponed	Word PDF	No fee
Form 40	Motion for Expedited Adjudication	Word PDF	$25.00
Form 51	Employer's Answer to Request for Hearing	Word PDF	No fee
Form 53	Employer's Answer to Request for Hearing, Death Case	Word PDF	No fee
Form 54	Employer's Notice of Claim and/or Request for Hearing	Word PDF	$25.00
Form 55	Second Injury Fund's Answer to Employee's Request for Hearing	Word PDF	No fee
Form 58	Pre-Hearing Brief	Word PDF	No fee
Form 59	Appellant’s Informal Brief	Word PDF	No fee
Form 65	Occupational Disease Waiver	Word PDF	No fee

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EDI Forms

	SC Trading Partner Profile	Word PDF
	SC WCC EDI Requirements Table	PDF

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About Filing Fees

There is a $25.00 fee for the following:

Clinchers, Settlements, Motions
Letters, motions, etc. requesting a dependency hearing
Third Party Settlements

The following are excluded from fees:

Requests for informal conferences and approval of Form 16 as a result of the viewing
Consent Orders/Motions/Petitions adding or deleting attorneys, protection orders for vacation, or to appoint guardian ad litems
Form 21, Sec II (b), Request to certify a Form 17
Hearings set on the Commission’s Motions due to no agreement being reached at the informal conference
Consent Orders that DO NOT require a hearing or a decision of a commissioner. A consent order which operates as a final settlement is considered to be a clincher and DOES require a fee.
If a filing is AMENDED, the amended form must be clearly marked as AMENDED, filed with the Commission and served on all parties. However, if the original document filed was exempt from the fee and you amend the document to file for relief that is not exempt from the fee, then a new form and fee must be filed.

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Claims Forms
Judicial Forms
Self-Insurance Forms
EDI Forms
About Filing Fees

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