|
Form # |
Name |
Download |
Filing Fee |
|
Form 5 |
Corporate Officer Notice to Reject |
Word PDF |
No fee |
|
Form 6 |
Application to Create a Self-Insurance Fund |
Word PDF |
$250.00 |
|
Form 6A |
Application for Membership in a Self-Insured Fund |
Word PDF |
$25.00 |
|
Form 7 |
Application to Individually Self-Insure |
Word PDF |
$250.00 plus $100.00 for each subsidiary |
|
Form 7A |
Corporate Guaranty |
Word PDF |
No fee |
|
Form 8 |
SC Workers’ Com. Comm. Bond Required of Employer Carrying His On Risk |
Word PDF |
No fee
|
|
Form 8B |
Irrevocable Letter of Credit |
Word PDF |
No fee |
|
Form 10 |
South Carolina Self-Insurance Tax Form |
Word PDF
|
No fee
|
|
Form 11 |
Fund Quarterly Financial Report |
Word PDF |
No fee |
|
Form 12A |
First Report of Injury |
Word PDF |
No fee |
|
Form 12M |
Annual Minor Medical Report |
Word PDF |
No fee |
|
Form 14A |
Health Insurance Claim Form |
PDF |
No fee |
|
Form 14B |
Physician’s Statement |
Word PDF |
No fee |
|
Form 15 |
Temporary Compensation Report |
Word PDF |
$25.00 for Section III only |
|
Form 15S |
Supplemental Report of Varying Temporary Partial Payments |
Word PDF |
No fee |
|
Form 16 |
Agreement for Permanent Disability/ Disfigurement Compensation |
Word PDF |
$25.00 if Claimant is represented |
|
Form 16A |
Agreement for Permanent Disability/ Disfigurement Compensation
Please complete this form for injuries occurring after July 1, 2007. |
Word PDF |
$25.00 if Claimant is represented |
|
Form 17 |
Receipt of Compensation |
Word PDF |
No fee |
|
Form 18 |
Periodic Report |
Word PDF |
No fee |
|
Form 19 |
Status Report and Compensation Receipt |
Word PDF |
No fee |
|
Form 20 |
Statement of Earning of Injured Employee |
Word PDF |
No fee |
|
Form 21 |
Employer's Request for Hearing |
Word PDF |
$25.00 |
|
Form 24 |
Application for Lump Sum Award |
Word PDF |
$25.00 |
|
Form 27 |
Subpoena |
Word PDF |
No fee |
|
Form 30 |
Request for Commission Review |
Word PDF |
$150.00 |
|
Form 32 |
Request to Waive Appeal Filing Fee |
Word PDF |
No fee |
|
Form 33 |
Hearing Postponed |
Word PDF |
No fee |
|
Form 38 |
Employer’s Withdrawal of Election to Adopt the South Carolina Workers’ Compensation Act |
Word PDF |
No fee |
|
Form 40 |
Motion for Expedited Adjudication |
Word PDF |
$25.00 |
|
Form 50 |
Employee's Notice of Claim and or Request for Hearing |
Word PDF |
$25.00 for Request for Hearing only |
|
Form 51 |
Employer's Answer to Request for Hearing |
Word PDF |
No fee |
|
Form 52 |
Employee's Notice of Claim and/or Request for Hearing |
Word |
$25.00 for Request for Hearing only |
|
Form 53 |
Employer's Answer to Request for Hearing, Death Case |
Word PDF |
No fee |
|
Form 54 |
Employer's Notice of Claim and/or Request for Hearing |
Word PDF |
$25.00 |
|
Form 55 |
Second Injury Fund's Answer to Employee's Request for Hearing |
Word PDF |
No fee |
|
Form 58 |
Pre-Hearing Brief |
Word PDF |
No fee |
|
Form 59 |
Appellant’s Informal Brief |
Word PDF |
No fee |
|
Form 61 |
Attorney Fee Petition |
Word PDF |
No fee |
|
Form 61A |
Attorney Fee Petition
Must accompany Form 61 |
Word PDF |
No fee |
|
Form 65 |
Occupational Disease Waiver |
Word PDF |
No fee |
|
Form S-1 |
Notice of Third Party Action Employee Carrier |
Word PDF |
No fee |
|
Form S-2 |
Notice of Third Party Action Employee |
Word PDF |
No fee |
|
Form S-3 |
Entitlement to Right of Action |
Word PDF |
No fee |
|
Form S-4 |
Court Certificate |
Word PDF |
No fee |
|
N/A |
Coverage Coding sheet for Attorneys |
Word PDF |
No fee |