The Official Web Site of the State of South Carolina

The Commission is currently recruiting for a Self-Insurance Director. Interested applicants may view the job posting here and apply online here.

 

On May 8, 2025, the Senate confirmed the reappointment of Commissioners Beck, Campbell, and McCaskill. We congratulate each of them on their confirmation and thank them for their continued dedication and service. Read more here.

 

The South Carolina Workers’ Compensation Commission is pleased to welcome Commissioner John Gabriel “Gabe” Coggiola, who has been appointed to serve the unexpired term of former Commissioner Avery B. Wilkerson, Jr., from July 1, 2020, through June 30, 2026. Read more 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 #DescriptionPDFDOCeFileFiling Fee
5Corporate Officer Notice to RejectPDFDocRequires a NotaryNo fee
6Application to Create a Self-Insurance FundPDFDocRequires a Notary$250.00
6AApplication for Membership in a Self-Insured FundPDF eFile$25.00
7Application to Individually Self-InsurePDFDocRequires a Notary$250.00 plus $100.00 for each subsidiary
7ACorporate GuarantyPDFDocRequires a Corporate SealNo fee
8SC Workers’ Compensation Commission Bond Required of
Employer Carrying His Own Risk		PDFDocRequires a NotaryNo fee
8BIrrevocable Letter of CreditPDFDocFuture ReleaseNo fee
10South Carolina Self-Insurance Tax FormPDF eFileNo fee
11Fund Quarterly Financial ReportPDFDoceFileNo fee
12AFirst Report of InjuryPDFDocN/ANo fee
12MAnnual Minor Medical ReportPDFDoceFileNo fee
14AHealth Insurance Claim FormPDFDoc Format
Not Available		N/ANo fee
14BPhysician’s StatementPDFDoceFileNo fee
15Temporary Compensation ReportPDFDoceFileNo fee (Unless Hearing requested for Section III)
15Temporary Compensation Report (Amended/Corrected)PDFDocPendingNo fee 
15Hearing Request to dispute the termination or suspension of temporary compensation on Form 15PDFDoceFile$50.00 for (Hearing Request Section III only)
15Hearing Request to dispute the termination or suspension of temporary compensation on Form 15 (Amended/Corrected)PDFDocPendingNo fee
15SSupplemental Report of Varying Temporary Partial PaymentsPDFDoceFileNo fee
16Agreement for Permanent Disability / Disfigurement CompensationPDFDoceFile$50.00 if Claimant is represented
16A

Agreement for Permanent Disability / Disfigurement Compensation

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

PDFDoceFile$50.00 if Claimant is represented
17Receipt of CompensationPDFDoceFileNo fee
18Periodic ReportPDFDoceFileNo fee
19Status Report and Compensation ReceiptPDFDoceFileNo fee
20Statement of Earning of Injured EmployeePDFDoceFileNo fee
21Employer's Request for HearingPDFDoceFile$50.00
21Employer's Request for Hearing (Amended/Corrected)PDFDocPendingNo fee
24Application for Lump Sum AwardPDFDoceFile$50.00
27SubpoenaPDFDoceFileNo fee
30Request for Commission ReviewPDFDoceFile$150.00
32Request to Waive Filing FeePDFDoceFileNo fee
33Hearing PostponedPDFDocN/ANo fee
38Employer’s Withdrawal of Election to Adopt the
South Carolina Workers’ Compensation Act		PDFDocRequires a NotaryNo fee
39Coverage Coding SheetPDFDocN/ANo fee
50Employee's Notice of Claim (No Hearing requested)PDFDoceFileNo fee (If Hearing is not requested)
50Employee's Notice of Claim (No Hearing requested) (Amended/Corrected)PDFDoceFileNo fee 
50Employee's Notice of Claim (Hearing is requested)PDFDoceFile$50.00 for (Request for Hearing only)
50Employee's Notice of Claim (Hearing is requested) (Amended/Corrected)PDFDoceFileNo fee
51Employer's Answer to Request for HearingPDFDoceFileNo fee
52Employee's Notice of Claim, Death Case (No Hearing requested)PDFDoceFileNo fee (If Hearing is not requested)
52Employee's Notice of Claim, Death Case (No Hearing requested) (Amended/Corrected)PDFDocPendingNo fee
52Employee's Notice of Claim, Death Case (Hearing is requested)PDFDoceFile$50.00 for (Request for Hearing only)
52Employee's Notice of Claim and or Request for Hearing, Death Case (Amended/Corrected)PDFDocPendingNo fee 
53Employer's Answer to Request for Hearing, Death CasePDFDoceFileNo fee
54Employer's Notice of Claim and/or Request for HearingPDFDoceFile$50.00
55Second Injury Fund's Answer to Employee's Request for HearingPDFDoceFileNo fee
58Pre-Hearing BriefPDFDoceFileNo fee
59Appellant’s Informal BriefPDFDoceFileNo fee
61Attorney Fee PetitionPDFDoceFileNo fee
61 OrderAttorney Fee PetitionPDFDoceFileNo fee
61AAttorney Fee Petition Supplemental InformationPDFDoceFileNo fee
65Occupational Disease WaiverPDFDoceFileNo fee
70Mediator ReportPDFDoceFileNo fee
S-1Notice of Third-Party Action Employee CarrierPDFDoceFileNo fee
S-2Notice of Third-Party Action EmployeePDFDoceFileNo fee
S-3Entitlement to Right of ActionPDFDoceFileNo fee
S-4Court CertificatePDFDoceFileNo fee
 Single Commissioner Decision & Order Template DocN/ANo fee
 Appellate Panel Decision & Order Template DocN/ANo 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 RequestPDF Requires a Notary$25.00
 Certificate of Service DocN/ANo fee

 

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Self-Insurance Forms

Form 6 Application to Create a Self-Insurance FundPDFDocRequires a Notary$250.00
Form 6A Application for Membership in a Self-Insured FundPDF eFile$25.00
Form 7 Application to Individually Self-InsurePDFDocRequires a Notary$250.00 plus $100.00 for each subsidiary
Form 7ACorporate GuarantyPDFDocRequires a Corporate SealNo fee
Form 8 SC Workers’ Compensation Commission Bond Required of
Employer Carrying His Own Risk		PDFDocRequires a NotaryNo fee
Form 8B Irrevocable Letter of CreditPDFDocFuture ReleaseNo fee
Form 10 South Carolina Self-Insurance Tax Form
(for calculations, Java scripting must be enabled in Adobe Reader)		PDF eFileNo fee
Form 11 Fund Quarterly Financial ReportPDFDoceFileNo fee

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Claims Forms

FormDescriptionPDFDOCeFileFee
Form 12AFirst Report of InjuryPDF DocN/ANo fee
Form 12MAnnual Minor Medical ReportPDFDoceFileNo fee
Form 14AHealth Insurance Claim FormPDFWord Format
not Available		N/ANo fee
Form 14BPhysician's StatementPDF DoceFileNo fee
Form 15Temporary Compensation ReportPDF DoceFileNo fee (Unless Hearing requested for Section III)
Form 15Temporary Compensation Report (Amended/Corrected)PDFDocPendingNo fee 
Form 15Hearing Request to dispute the termination or suspension of temporary compensation on Form 15PDFDoceFile$50.00 for (Hearing Request Section III only)
Form 15Hearing Request to dispute the termination or suspension of temporary compensation on Form 15 (Amended/Corrected)PDFDocPendingNo fee
Form 15SSupplemental Report of Varying
Temporary Partial Payments    		PDFDoceFileNo fee
Form 16Agreement for Permanent
Disability/Disfigurement Compensation		PDFDoceFile$50.00 if filed by
Claimant's Attorney
Form 16AAgreement for Permanent
Disability/Disfigurement Compensation

Please complete this form for injuries occurring
after July 1, 2007		PDFDoceFile$50.00 if filed by
Claimant's Attorney
Form 17Receipt of CompensationPDFDoceFileNo fee
Form 18Periodic ReportPDFDoceFileNo fee
Form 19Saturation Report and Compensation ReportPDFDoceFileNo fee
Form 20Statement of Earnings of Injured EmployeePDFDoceFileNo fee
Form 24Application for Lump Sum AwardPDFDoceFile$50.00
Form 50Employee's Notice of Claim (No Hearing requested)PDFDoceFileNo fee (If Hearing is not requested)
Form 50Employee's Notice of Claim (No Hearing requested) (Amended/Corrected)PDFDoceFileNo fee 
Form 50Employee's Notice of Claim (Hearing is requested)PDFDoceFile$50.00 for (Request for Hearing only)
Form 50Employee's Notice of Claim (Hearing is requested) (Amended/Corrected)PDFDoceFileNo fee
Form 52Employee's Notice of Claim, Death Case (No Hearing requested)PDFDoceFileNo fee (If Hearing is not requested)
Form 52Employee's Notice of Claim, Death Case (No Hearing requested) (Amended/Corrected)PDFDocPendingNo fee
Form 52Employee's Notice of Claim, Death Case (Hearing is requested)PDFDoceFile$50.00 for (Request for Hearing only)
Form 52Employee's Notice of Claim and or Request for Hearing, Death Case (Amended/Corrected)PDFDocPendingNo fee
Form 61Attorney Fee PetitionPDFDoceFileNo fee
Form S-1Notice of Third Party Action Employee CarrierPDFDoceFileNo fee
Form S-2Notice of Third Party Action EmployeePDFDoceFileNo fee

 

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Judicial Forms

FormDescriptionPDFDoceFileFee
21Employer's Request for HearingPDFDoceFile$50.00
21Employer's Request for Hearing (Amended/Corrected)PDFDocPendingNo Fee
27SubpoenaPDFDoceFileNo Fee
30Request for Commission ReviewPDFDoceFile$150
32Request to Waive Appeal Filing
Fee		PDFDoceFileNo Fee
33Hearing PostponedPDFDocN/ANo Fee
50Employee's Notice of Claim (No Hearing requested)PDFDoceFileNo fee (If Hearing is not requested)
50Employee's Notice of Claim (No Hearing requested) (Amended/Corrected)PDFDoceFileNo fee 
50Employee's Notice of Claim (Hearing is requested)PDFDoceFile$50.00 for (Request for Hearing only)
50 Employee's Notice of Claim (Hearing is requested) (Amended/Corrected)PDFDoceFileNo fee
51Employer's Answer to Request
for Hearing		PDFDoceFileNo Fee
52Employee's Notice of Claim, Death Case (No Hearing requested)PDFDoceFileNo fee (If Hearing is not requested)
52Employee's Notice of Claim, Death Case (No Hearing requested) (Amended/Corrected)PDFDocPendingNo fee
52Employee's Notice of Claim, Death Case (Hearing is requested) PDFDoceFile$50.00 for (Request for Hearing only)
52Employee's Notice of Claim and or Request for Hearing, Death Case (Amended/Corrected)PDFDocPendingNo fee
53Employer's Answer to Request
for Hearing, Death, Case		PDFDoceFileNo Fee
54Employer's Notice of Claim
and/or Request for Hearing		PDFDoceFile$50.00
55Second Injury Fund's
Answer to Employee's Request
for Hearing		PDFDoceFileNo Fee
58Pre-Hearing BriefPDFDoceFileNo Fee
59Appellant's Informational BriefPDFDoceFileNo Fee
65Occupational Disease WaiverPDFDoceFileNo Fee
70Mediator ReportPDFDoceFileNo Fee
 Single Commissioner Decision & Order Template DocN/ANo Fee
 Appellate Panel Decision & Order Template DocN/ANo Fee
 Certificate of Service DocN/ANo 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

There is a $25.00 fee for the following:
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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