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The Official Web Site of the State of South Carolina

Forms

Forms

The South Carolina Workers' Compensation Commission offers all of its forms in PDF fillable format, or that they can be printed out and completed manually.

Please note that each field has limited space. If more space is required for any field on the form, please attach additional pages as necessary. These forms require a free Adobe Acrobat Reader to open and print them. If you are getting a message about an "unknown file type" when downloading our forms, please download the free Adobe Acrobat Reader.

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

 

Form # Description PDF DOC Filing Fee
5

Corporate Officer Notice to Reject

PDF Doc

No fee

6

Application to Create a Self-Insurance Fund

PDF Doc $250.00
6A

Application for Membership in a Self-Insured Fund

PDF Doc $50.00
7

Application to Individually Self-Insure

PDF Doc $250.00 plus $100.00 for each subsidiary
7A

Corporate Guaranty

PDF Doc No fee
8

SC Workers’ Compensation Commission Bond Required of
Employer Carrying His Own Risk

PDF Doc No fee
8B

Irrevocable Letter of Credit

PDF Doc No fee
10 South Carolina Self-Insurance Tax Form PDF Doc No fee
11

Fund Quarterly Financial Report

PDF Doc No fee
12A

First Report of Injury

PDF Doc No fee
12M Annual Minor Medical Report PDF Doc No fee
14A Health Insurance Claim Form PDF Doc Format
Not Available
No fee
14B

Physician’s Statement

PDF Doc No fee
15 Temporary Compensation Report PDF Doc $50.00 for Section III only
15S Supplemental Report of Varying Temporary Partial Payments PDF Doc No fee
16 Agreement for Permanent Disability / Disfigurement Compensation PDF Doc $50.00 if Claimant is represented
16A

Agreement for Permanent Disability / Disfigurement Compensation

Please complete this form for injuries occurring after July 1, 2007.

PDF Doc

$50.00 if Claimant is represented

17

Receipt of Compensation

PDF Doc No fee
18 Periodic Report PDF Doc No fee
19 Status Report and Compensation Receipt PDF Doc No fee
20 Statement of Earning of Injured Employee PDF Doc No fee
21 Employer's Request for Hearing PDF Doc

$50.00

22

Claimant's Answer to Request for Hearing

PDF Doc No fee
24

Application for Lump Sum Award

PDF Doc

$50.00

27 Subpoena PDF Doc No fee
30

Request for Commission Review

PDF Doc

$150.00

32

Request to Waive Appeal Filing Fee

PDF Doc No fee
33

Hearing Postponed

PDF Doc No fee
38

Employer’s Withdrawal of Election to Adopt the
South Carolina Workers’ Compensation Act

PDF Doc No fee
39

Coverage Coding Sheet

PDF Doc No fee
50

Employee's Notice of Claim and or Request for Hearing

PDF Doc $50.00 for Request for Hearing only
51

Employer's Answer to Request for Hearing

PDF Doc No fee
52

Employee's Notice of Claim and/or Request for Hearing

PDF Doc

$50.00 for Request for Hearing only

53

Employer's Answer to Request for Hearing, Death Case

PDF Doc No fee
54

Employer's Notice of Claim and/or Request for Hearing

PDF Doc

$50.00

55

Second Injury Fund's Answer to Employee's Request for Hearing

PDF Doc No fee
58

Pre-Hearing Brief

PDF Doc No fee
59

Appellant’s Informal Brief

PDF Doc No fee
61

Attorney Fee Petition

PDF Doc No fee
61 Order

Attorney Fee Petition

PDF Doc No fee
61A

Attorney Fee Petition Supplemental Information

PDF Doc No fee
65

Occupational Disease Waiver

PDF Doc No fee
70

Mediator Report

PDF Doc No fee
S-1

Notice of Third Party Action Employee Carrier

PDF Doc No fee
S-2

Notice of Third Party Action Employee

PDF Doc No fee
S-3

Entitlement to Right of Action

PDF Doc No fee
S-4

Court Certificate

PDF Doc No fee

 

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Self-Insurance Forms

Form 6  Application to Create a Self-Insurance Fund Doc PDF $250.00
Form 6A  Application for Membership in a Self-Insured Fund Doc PDF $50.00
Form 7  Application to Individually Self-Insure Doc PDF $250.00 plus $100.00 for each subsidiary
Form 7A Corporate Guaranty Doc PDF No fee
Form 8  SC Workers’ Com. Comm. Bond Required of Employer Carrying His On Risk Doc PDF No fee
Form 8B  Irrevocable Letter of Credit Doc PDF No fee
Form 10  South CarolinaSelf-Insurance Tax Form
(for calculations, Java scripting must be enabled in Adobe Reader)
Doc PDF No fee
Form 11  Fund Quarterly Financial Report Doc PDF No fee

 

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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 $50.00for 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

 

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Judicial Forms

Form Description PDF Doc Fee
21 Employer's Request for Hearing PDF Doc $50.00
22 Claimant's Answer to Request
for Hearing
PDF Doc No Fee
27 Subpeana PDF Doc No Fee
30 Request for Commission Review PDF Doc $150
32 Request to Waive Appeal Filing
Fee
PDF Doc No Fee
33 Hearing Postponed PDF Doc No Fee
51 Employer's Answer to Request
for Hearing
PDF Doc No Fee
53 Employer's Answer to Request
for Hearing, Death, Case
PDF Doc No Fee
54 Employer's Notice of Claim
and/or Request for Hearing
PDF Doc $50.00
55 Second Injury Fund's
Answer to Employee's Request
for Hearing
PDF Doc No Fee
58 Pre-Hearing Brief PDF Doc No Fee
59 Appellant's Informational Brief PDF Doc No Fee
65 Occupational Disease Waiver PDF Doc No Fee
70 Mediator Report PDF Doc No Fee

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About Filing Fees

There is a $50.00 fee for the following:
Clinchers, Settlements, Motions 
Consent Orders that operate as a final settlement
A Consent Order that is reached when no hearing is pending
Letters, motions, etc. requesting a dependency hearing 
Third Party Settlements
Motion for Relief of Counsel
Motion to add a party (ADDING A PARTY VIA AMENDED FORM 50 NO LONGER ALLOWED

 

The following are excluded from fees:
Requests for informal conferences and approval of Form 16 as a result of the viewing
Requests for Protection
Motion to appoint a guardian ad litem
Hearings set on the Commission's Motions due to no agreement being reached at the informal conference
Letter adding an attorney
Motion for substitution of counsel within the same firm

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