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The Official Web Site of the State of South Carolina

Claims Forms

Form Description PDF DOC Fee
Form 12A First Report of Injury PDF  Doc No fee
Form 12M Annual Minor Medical Report PDF Doc No fee
Form 14A Health Insurance Claim Form PDF Word Format
not Available
No fee
Form 14B Physician's Statement PDF  Doc No fee
Form 15 Temporary Compensation Report PDF  Doc $50.00 for
Section III only
Form 15S Supplemental Report of Varying
Temporary Partial Payments    
PDF Doc No fee
Form 16 Agreement for Permanent
Disability/Disfigurement Compensation
PDF Doc $50.00 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
PDF Doc $50.00 if filed by
Claimant's Attorney
Form 17 Receipt of Compensation PDF Doc No fee
Form 18 Periodic Report PDF Doc No fee
Form 19 Saturation Report and Compensation Report PDF Doc No fee
Form 20 Statement of Earnings of Injured Employee PDF Doc No fee
Form 24 Application for Lump Sum Award PDF Doc $50.00
Form 50 Employee's Notice of Claim and or Request
for Hearing
PDF Doc $50.00 for Request
for Hearing only
Form 52 Employee's Notice of Claim and/or Request
for Hearing
PDF Doc $50.00 for Request
for Hearing only
Form 61 Attorney Fee Petition PDF Doc No fee
Form S-1 Notice of Third Party Action Employee Carrier PDF Doc No fee
Form S-2 Notice of Third Party Action Employee PDF Doc No fee