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 | DOC | eFile | Filing Fee | |
|---|---|---|---|---|---|
| 5 |
Corporate Officer Notice to Reject |
Doc | Requires a Notary |
No fee |
|
| 6 |
Application to Create a Self-Insurance Fund |
Doc | Requires a Notary | $250.00 | |
| 6A |
Application for Membership in a Self-Insured Fund |
eFile | $25.00 | ||
| 7 |
Application to Individually Self-Insure |
Doc | Requires a Notary | $250.00 plus $100.00 for each subsidiary | |
| 7A |
Corporate Guaranty |
Doc | Requires a Corporate Seal | No fee | |
| 8 |
SC Workers’ Compensation Commission Bond Required of |
Doc | Requires a Notary | No fee | |
| 8B |
Irrevocable Letter of Credit |
Doc | Future Release | No fee | |
| 10 | South Carolina Self-Insurance Tax Form | eFile | No fee | ||
| 11 |
Fund Quarterly Financial Report |
Doc | eFile | No fee | |
| 12A |
First Report of Injury |
Doc | N/A | No fee | |
| 12M | Annual Minor Medical Report | Doc | eFile | No fee | |
| 14A | Health Insurance Claim Form | Doc Format Not Available |
N/A | No fee | |
| 14B |
Physician’s Statement |
Doc | eFile | No fee | |
| 15 | Temporary Compensation Report | 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 | Doc | eFile | $50.00 for (Hearing Request Section III only) | |
| 15S | Supplemental Report of Varying Temporary Partial Payments | Doc | eFile | No fee | |
| 16 | Agreement for Permanent Disability / Disfigurement Compensation | 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. |
Doc | eFile |
$50.00 if Claimant is represented |
|
| 17 |
Receipt of Compensation |
Doc | eFile | No fee | |
| 18 | Periodic Report | Doc | eFile | No fee | |
| 19 | Status Report and Compensation Receipt | Doc | eFile | No fee | |
| 20 | Statement of Earning of Injured Employee | Doc | eFile | No fee | |
| 21 | Employer's Request for Hearing | Doc | eFile |
$50.00 |
|
| 21 |
Employer's Request for Hearing (Amended/Corrected) |
Doc | Pending | No fee | |
| 24 |
Application for Lump Sum Award |
Doc | eFile |
$50.00 |
|
| 27 | Subpoena | Doc | eFile | No fee | |
| 30 |
Request for Commission Review |
Doc | eFile |
$150.00 |
|
| 32 |
Request to Waive Filing Fee |
Doc | eFile | No fee | |
| 33 |
Hearing Postponed |
Doc | N/A | No fee | |
| 38 |
Employer’s Withdrawal of Election to Adopt the |
Doc | Requires a Notary | No fee | |
| 39 |
Coverage Coding Sheet |
Doc | N/A | No fee | |
| 50 |
Employee's Notice of Claim (No Hearing requested) |
Doc | eFile | No fee (If Hearing is not requested) | |
| 50 |
Employee's Notice of Claim (Hearing is requested) |
Doc | eFile | $50.00 for (Request for Hearing only) | |
| 50 | Employee's Notice of Claim and or Request for Hearing (Amended/Corrected) | Doc | eFile | No fee | |
| 51 |
Employer's Answer to Request for Hearing |
Doc | No fee | ||
| 52 |
Employee's Notice of Claim, Death Case (No Hearing requested) |
Doc | eFile | No fee (If Hearing is not requested) | |
| 52 |
Employee's Notice of Claim, Death Case (Hearing is requested) |
Doc | eFile |
$50.00 for (Request for Hearing only) |
|
|
52 |
Employee's Notice of Claim and or Request for Hearing, Death Case (Amended/Corrected) | Doc | Future Release | No fee | |
| 53 |
Employer's Answer to Request for Hearing, Death Case |
Doc | eFile | No fee | |
| 54 |
Employer's Notice of Claim and/or Request for Hearing |
Doc | eFile |
$50.00 |
|
| 55 |
Second Injury Fund's Answer to Employee's Request for Hearing |
Doc | No fee | ||
| 58 |
Pre-Hearing Brief |
Doc | eFile | No fee | |
| 59 |
Appellant’s Informal Brief |
Doc | eFile | No fee | |
| 61 |
Attorney Fee Petition |
Doc | eFile | No fee | |
| 61 Order |
Attorney Fee Petition |
Doc | eFile | No fee | |
| 61A |
Attorney Fee Petition Supplemental Information |
Doc | eFile | No fee | |
| 65 |
Occupational Disease Waiver |
Doc | eFile | No fee | |
| 70 |
Mediator Report |
Doc | eFile | No fee | |
| S-1 |
Notice of Third-Party Action Employee Carrier |
Doc | eFile | No fee | |
| S-2 |
Notice of Third-Party Action Employee |
Doc | eFile | No fee | |
| S-3 |
Entitlement to Right of Action |
Doc | eFile | No fee | |
| S-4 |
Court Certificate |
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) | eFile | $20.00 for first 20 pages, search, redaction & retrieval of file; $0.50 per page thereafter | |||
| Pre-Employment Verification Request | Requires a Notary | $25.00 | |||
| Certificate of Service | Doc | N/A | No fee |
| Form 6 | Application to Create a Self-Insurance Fund | Doc | Requires a Notary | $250.00 | |
| Form 6A | Application for Membership in a Self-Insured Fund | eFile | $25.00 | ||
| Form 7 | Application to Individually Self-Insure | Doc | Requires a Notary | $250.00 plus $100.00 for each subsidiary | |
| Form 7A | Corporate Guaranty | Doc | Requires a Corporate Seal | No fee | |
| Form 8 | SC Workers’ Compensation Commission Bond Required of Employer Carrying His Own Risk |
Doc | Requires a Notary | No fee | |
| Form 8B | Irrevocable Letter of Credit | Doc | Future Release | No fee | |
| Form 10 | South Carolina Self-Insurance Tax Form (for calculations, Java scripting must be enabled in Adobe Reader) |
eFile | No fee | ||
| Form 11 | Fund Quarterly Financial Report | Doc | eFile | No fee |
Claims Forms
| Form | Description | DOC | eFile | Fee | |
|---|---|---|---|---|---|
| Form 12A | First Report of Injury | Doc | N/A | No fee | |
| Form 12M | Annual Minor Medical Report | Doc | eFile | No fee | |
| Form 14A | Health Insurance Claim Form | Word Format not Available |
N/A | No fee | |
| Form 14B | Physician's Statement | Doc | eFile | No fee | |
| Form 15 | Temporary Compensation Report | Doc | eFile | $50.00 for Section III only |
|
| Form 15 | Hearing Request to dispute the termination or suspension of temporary compensation on Form 15 | Doc | eFile | $50.00 for (Hearing Request Section III only) | |
| Form 15S | Supplemental Report of Varying Temporary Partial Payments |
Doc | eFile | No fee | |
| Form 16 | Agreement for Permanent Disability/Disfigurement Compensation |
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 |
Doc | eFile | $50.00 if filed by Claimant's Attorney |
|
| Form 17 | Receipt of Compensation | Doc | eFile | No fee | |
| Form 18 | Periodic Report | Doc | eFile | No fee | |
| Form 19 | Saturation Report and Compensation Report | Doc | eFile | No fee | |
| Form 20 | Statement of Earnings of Injured Employee | Doc | eFile | No fee | |
| Form 24 | Application for Lump Sum Award | Doc | eFile | $50.00 | |
| Form 50 | Employee's Notice of Claim (No Hearing requested) | Doc | eFile | No fee (If Hearing is not requested) | |
| Form 50 | Employee's Notice of Claim (Hearing is requested) | Doc | eFile | $50.00 for (Request for Hearing only) | |
| Form 50 | Employee's Notice of Claim and or Request for Hearing (Amended/Corrected) | Doc | eFile | No fee | |
| Form 52 | Employee's Notice of Claim, Death Case (No Hearing requested) | Doc | eFile | No fee (If Hearing is not requested) | |
| Form 52 | Employee's Notice of Claim, Death Case (Hearing is requested) | 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) | Doc | Future Release | No fee | |
| Form 61 | Attorney Fee Petition | Doc | eFile | No fee | |
| Form S-1 | Notice of Third Party Action Employee Carrier | Doc | eFile | No fee | |
| Form S-2 | Notice of Third Party Action Employee | Doc | eFile | No fee |
Judicial Forms
| Form | Description | Doc | eFile | Fee | |
|---|---|---|---|---|---|
| 21 | Employer's Request for Hearing | Doc | eFile | $50.00 | |
| 21 | Employer's Request for Hearing (Amended/Corrected) | Doc | Pending | No Fee | |
| 27 | Subpoena | Doc | eFile | No Fee | |
| 30 | Request for Commission Review | Doc | eFile | $150 | |
| 32 | Request to Waive Appeal Filing Fee |
Doc | eFile | No Fee | |
| 33 | Hearing Postponed | Doc | N/A | No Fee | |
| 50 | Employee's Notice of Claim (No Hearing requested) | Doc | eFile | No fee (If Hearing is not requested) | |
| 50 | Employee's Notice of Claim (Hearing is requested) | Doc | eFile |
$50.00 for (Request for Hearing only) |
|
| 50 | Employee's Notice of Claim and or Request for Hearing (Amended/Corrected) | Doc | eFile | No fee | |
| 51 | Employer's Answer to Request for Hearing |
Doc | eFile | No Fee | |
| 52 | Employee's Notice of Claim, Death Case (No Hearing requested) | Doc | eFile | No fee (If Hearing is not requested) | |
| 52 | Employee's Notice of Claim, Death Case (Hearing is requested) | Doc | eFile | $50.00 for (Request for Hearing only) | |
| 52 | Employee's Notice of Claim and or Request for Hearing, Death Case (Amended/Corrected) | Doc | Future Release | No fee | |
| 53 | Employer's Answer to Request for Hearing, Death, Case |
Doc | eFile | No Fee | |
| 54 | Employer's Notice of Claim and/or Request for Hearing |
Doc | eFile | $50.00 | |
| 55 | Second Injury Fund's Answer to Employee's Request for Hearing |
Doc | eFile | No Fee | |
| 58 | Pre-Hearing Brief | Doc | eFile | No Fee | |
| 59 | Appellant's Informational Brief | Doc | eFile | No Fee | |
| 65 | Occupational Disease Waiver | Doc | eFile | No Fee | |
| 70 | Mediator Report | 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 |
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