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The Official Web Site of the State of South Carolina
The Commission recognizes Mr. Duane Earles for 50 years of service! The full advisory may be accessed here
The Commission received the final report from the Office of State Auditor on June 26, 2024. The full report may be accessed here. The report is the result of an annual audit of the Commission's internal financial activity. 
 Regulation 67-1602 has been amended to establish electronic payment systems as the default method of payment for temporary disability and reimbursement for expenses. The full advisory and text of the regulation may be accessed here

 

 
 

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 or payments, the eFile and ePay submission tutorial may be accessed here. If additional assistance is needed, please contact the Commission.  All forms have a direct phone number listed for assistance.

 

Form # Description PDF DOC eFile Filing Fee
5

Corporate Officer Notice to Reject

PDF Doc Requires a Notary

No fee

6

Application to Create a Self-Insurance Fund

PDF Doc Requires a Notary $250.00
6A

Application for Membership in a Self-Insured Fund

PDF   eFile $25.00
7

Application to Individually Self-Insure

PDF Doc Requires a Notary $250.00 plus $100.00 for each subsidiary
7A

Corporate Guaranty

PDF Doc Requires a Corporate Seal No fee
8

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

PDF Doc Requires a Notary No fee
8B

Irrevocable Letter of Credit

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

Fund Quarterly Financial Report

PDF Doc eFile No fee
12A

First Report of Injury

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

Physician’s Statement

PDF Doc eFile No fee
15 Temporary Compensation Report PDF Doc eFile No fee (Unless Hearing requested for Section III)
15 Hearing Request to dispute the termination or suspension of temporary compensation on Form 15 PDF Doc eFile $50.00 for (Hearing Request Section III only)
15S Supplemental Report of Varying Temporary Partial Payments PDF Doc eFile No fee
16 Agreement for Permanent Disability / Disfigurement Compensation PDF Doc eFile $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 eFile

$50.00 if Claimant is represented

17

Receipt of Compensation

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

$50.00

24

Application for Lump Sum Award

PDF Doc eFile

$50.00

27 Subpoena PDF Doc eFile No fee
30

Request for Commission Review

PDF Doc eFile

$150.00

32

Request to Waive Filing Fee

PDF Doc eFile No fee
33

Hearing Postponed

PDF Doc N/A No fee
38

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

PDF Doc Requires a Notary No fee
39

Coverage Coding Sheet

PDF Doc N/A No fee
50

Employee's Notice of Claim (No Hearing requested)

PDF Doc eFile No fee (If Hearing is not requested)
50

Employee's Notice of Claim (Hearing is requested)

PDF Doc eFile $50.00 for (Request for Hearing only)
50 Employee's Notice of Claim and or Request for Hearing (Amended/Corrected) PDF Doc eFile No fee
51

Employer's Answer to Request for Hearing

PDF Doc

eFile

No fee
52

Employee's Notice of Claim, Death Case (No Hearing requested)

PDF Doc eFile No fee (If Hearing is not requested)
52

Employee's Notice of Claim, Death Case (Hearing is requested)

PDF Doc eFile

$50.00 for (Request for Hearing only)

52

Employee's Notice of Claim and or Request for Hearing, Death Case (Amended/Corrected) PDF Doc Future Release No fee 
53

Employer's Answer to Request for Hearing, Death Case

PDF Doc eFile No fee
54

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

PDF Doc eFile

$50.00

55

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

PDF Doc

eFile

No fee
58

Pre-Hearing Brief

PDF Doc eFile No fee
59

Appellant’s Informal Brief

PDF Doc eFile No fee
61

Attorney Fee Petition

PDF Doc eFile No fee
61 Order

Attorney Fee Petition

PDF Doc eFile No fee
61A

Attorney Fee Petition Supplemental Information

PDF Doc eFile No fee
65

Occupational Disease Waiver

PDF Doc eFile No fee
70

Mediator Report

PDF Doc eFile No fee
S-1

Notice of Third-Party Action Employee Carrier

PDF Doc eFile No fee
S-2

Notice of Third-Party Action Employee

PDF Doc eFile No fee
S-3

Entitlement to Right of Action

PDF Doc eFile No fee
S-4

Court Certificate

PDF Doc eFile No fee
  Single Commissioner Decision & Order Template   Doc N/A No fee
  Appellate Panel Decision & Order Template   Doc N/A No fee
  Authorization of Release of Claims Information (File Copy Request) PDF   eFile $20.00 for first 20 pages, search, redaction & retrieval of file; $0.50 per page thereafter
  Pre-Employment Verification Request PDF   Requires a Notary $25.00
  Certificate of Service   Doc N/A No fee

 

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Self-Insurance Forms

Form 6  Application to Create a Self-Insurance Fund PDF Doc Requires a Notary $250.00
Form 6A  Application for Membership in a Self-Insured Fund PDF   eFile $25.00
Form 7  Application to Individually Self-Insure PDF Doc Requires a Notary $250.00 plus $100.00 for each subsidiary
Form 7A Corporate Guaranty PDF Doc Requires a Corporate Seal No fee
Form 8  SC Workers’ Compensation Commission Bond Required of
Employer Carrying His Own Risk
PDF Doc Requires a Notary No fee
Form 8B  Irrevocable Letter of Credit PDF Doc Future Release No fee
Form 10  South Carolina Self-Insurance Tax Form
(for calculations, Java scripting must be enabled in Adobe Reader)
PDF   eFile No fee
Form 11  Fund Quarterly Financial Report PDF Doc eFile No fee

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Claims Forms

Form Description PDF DOC eFile Fee
Form 12A First Report of Injury PDF  Doc N/A No fee
Form 12M Annual Minor Medical Report PDF Doc eFile No fee
Form 14A Health Insurance Claim Form PDF Word Format
not Available
N/A No fee
Form 14B Physician's Statement PDF  Doc eFile No fee
Form 15 Temporary Compensation Report PDF  Doc eFile $50.00 for
Section III only
Form 15 Hearing Request to dispute the termination or suspension of temporary compensation on Form 15 PDF Doc eFile $50.00 for (Hearing Request Section III only)
Form 15S Supplemental Report of Varying
Temporary Partial Payments    
PDF Doc eFile No fee
Form 16 Agreement for Permanent
Disability/Disfigurement Compensation
PDF Doc eFile $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 eFile $50.00 if filed by
Claimant's Attorney
Form 17 Receipt of Compensation PDF Doc eFile No fee
Form 18 Periodic Report PDF Doc eFile No fee
Form 19 Saturation Report and Compensation Report PDF Doc eFile No fee
Form 20 Statement of Earnings of Injured Employee PDF Doc eFile No fee
Form 24 Application for Lump Sum Award PDF Doc eFile $50.00
Form 50 Employee's Notice of Claim (No Hearing requested) PDF Doc eFile No fee (If Hearing is not requested)
Form 50 Employee's Notice of Claim (Hearing is requested) PDF Doc eFile $50.00 for (Request for Hearing only)
Form 50 Employee's Notice of Claim and or Request for Hearing (Amended/Corrected) PDF Doc eFile No fee
Form 52 Employee's Notice of Claim, Death Case (No Hearing requested) PDF Doc eFile No fee (If Hearing is not requested)
Form 52 Employee's Notice of Claim, Death Case (Hearing is requested) PDF Doc eFile $50.00 for (Request for Hearing only)
Form 52 Employee's Notice of Claim and or Request for Hearing, Death Case (Amended/Corrected) PDF Doc Future Release No fee
Form 61 Attorney Fee Petition PDF Doc eFile No fee
Form S-1 Notice of Third Party Action Employee Carrier PDF Doc eFile No fee
Form S-2 Notice of Third Party Action Employee PDF Doc eFile No fee

 

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Judicial Forms

Form Description PDF Doc eFile Fee
21 Employer's Request for Hearing PDF Doc eFile $50.00
27 Subpoena PDF Doc eFile No Fee
30 Request for Commission Review PDF Doc eFile $150
32 Request to Waive Appeal Filing
Fee
PDF Doc eFile No Fee
33 Hearing Postponed PDF Doc N/A No Fee
50 Employee's Notice of Claim (No Hearing requested) PDF Doc eFile No fee (If Hearing is not requested)
50 Employee's Notice of Claim (Hearing is requested) PDF Doc eFile

$50.00 for (Request for Hearing only)

50  Employee's Notice of Claim and or Request for Hearing (Amended/Corrected) PDF Doc eFile No fee
51 Employer's Answer to Request
for Hearing
PDF Doc eFile No Fee
52 Employee's Notice of Claim, Death Case (No Hearing requested) PDF Doc eFile No fee (If Hearing is not requested)
52 Employee's Notice of Claim, Death Case (Hearing is requested)  PDF Doc eFile $50.00 for (Request for Hearing only)
52 Employee's Notice of Claim and or Request for Hearing, Death Case (Amended/Corrected) PDF Doc Future Release No fee
53 Employer's Answer to Request
for Hearing, Death, Case
PDF Doc eFile No Fee
54 Employer's Notice of Claim
and/or Request for Hearing
PDF Doc eFile $50.00
55 Second Injury Fund's
Answer to Employee's Request
for Hearing
PDF Doc eFile No Fee
58 Pre-Hearing Brief PDF Doc eFile No Fee
59 Appellant's Informational Brief PDF Doc eFile No Fee
65 Occupational Disease Waiver PDF Doc eFile No Fee
70 Mediator Report PDF Doc eFile No Fee
  Single Commissioner Decision & Order Template   Doc N/A No Fee
  Appellate Panel Decision & Order Template   Doc N/A No Fee
  Certificate of Service   Doc N/A No Fee

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About Filing Fees

There is a $50.00 fee for the following:
Clinchers, Settlements,
Clincher Conference Request
Consent Orders that operate as a final settlement
A Consent Order that is reached when no hearing is pending
Motion/Petition 
Third Party Settlements
Motion for Relief of Counsel
Motion to add a party
Claims History Request

 

 

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
Appellant Reply Brief
Respondent Brief
Dependency Investigation/Request for Dependency Hearing
Response to Form 21 Hearing Request
Response to Motion

 

 

To pay a fine issued by the Commission:
Electronic Fine Payment Form

eFile and ePay submission tutorial

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