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The Official Web Site of the State of South Carolina
PO Box 17151333 Main Street, Suite 500Columbia, SC 29202-1715803-737-5700

Forms
 

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

When using the PDF format, 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 #

Name

Download

Download

Filing Fee

Form 5

Revised
05/2013

Corporate Officer Notice to Reject

WORD

 

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 6
Revised
04/2000

 

Application to Create a Self-Insurance Fund

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$250.00

Form 6A
Created
03/1996

 

Application for Membership in a Self-Insured Fund

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00

Form 7

Created
03/1996

Application to Individually Self-Insure

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$250.00 plus $100.00 for each subsidiary

Form 7A

 

Corporate Guaranty

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 8

Revised
07/1996

SC Workers’ Com. Comm. Bond Required of Employer Carrying His Own Risk

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 8B

Revised
10/2014

Irrevocable Letter of Credit

WORD

 

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 10

Revised
07/1992

South Carolina Self-Insurance Tax Form
(for calculations, Java scripting must be enabled in Adobe Reader)

WORD

PDF


If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 11

Revised
03/1996

Fund Quarterly Financial Report

WORD

PDF

If more space is required for any field on the form, please attach additional pages as necessary 

No fee

Form 12A

Revised
04/2006

First Report of Injury

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 12M

Revised
05/2006

Annual Minor
Medical Report

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 14A

Revised
05/2006

Health Insurance Claim Form

WORD format not available

PDF

If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 14B

Revised
09/2013

Physician’s Statement

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 15

Revised

01/2014

Temporary Compensation Report

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00 for Section III only

Form 15S

Revised
03/1997

Supplemental Report of Varying Temporary Partial Payments

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 16

Revised
09/2007

Agreement for Permanent Disability/  Disfigurement Compensation

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00 if Claimant is represented

Form 16A

Revised

09/2013

Agreement for Permanent Disability/  Disfigurement Compensation

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

 


WORD

 

 

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00 if Claimant is represented

Form 17

Revised
01/2014

Receipt of Compensation

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 18

Revised
01/2014

Periodic Report

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 19

Revised
01/2014

Status Report and Compensation Receipt

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 20

Revised

01/2014

Statement of Earning of Injured Employee

WORD

 PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 21

Revised
07/2013

Employer's Request for Hearing

WORD

 

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00

Form 22

Created
07/2013

Claimant's Answer to Request for Hearing

WORD

 

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 24

Revised

09/1990

Application for Lump Sum Award

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00

Form 27

Revised
03/2014

Subpoena

WORD

 

PDF

If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 30

Revised
07/2013

Request for Commission Review

WORD

 

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$150.00

Form 32

Revised
07/2003

Request to Waive Appeal Filing Fee

WORD

 

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 33

Revised

07/2006

Hearing Postponed

WORD

      PDF

If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 38

Revised
01/1988

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

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 39

Revised

06/2010


 

Coverage Coding Sheet

WORD

PDF

If more space is required for any field on the form, please attach additional pages as necessary

No Fee

Form 50

Revised
07/2013

Employee's Notice of Claim and or Request for Hearing

WORD

 

PDF

If more space is required for any field on the form, please attach additional pages as necessary

$25.00 for Request for Hearing only

Form 51

Revised

07/2013

Employer's Answer to Request for Hearing

WORD

 

PDF
If more space is required for any field on the form, please attach additional pages as necessary
 

No fee

Form 52

Revised
07/2013

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

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00 for Request for Hearing only

Form 53

Revised
07/2013

Employer's Answer to Request for Hearing, Death Case

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 54

Revised

07/2013

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

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00

Form 55

Revised

07/2013

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

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 58

Revised
07/2013

Pre-Hearing Brief

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

 

No fee

Form 59

Revised
09/1990

Appellant’s Informal Brief

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

 

No fee

Form 61

Revised
07/2008

Attorney Fee Petition

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

61 Order

Attorney Fee Petition

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

61A
Revised
10/2007

Attorney Fee Petition Supplemental Information

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 65

Revised
01/1997

Occupational Disease Waiver

WORD

PDF

If more space is required for any field on the form, please attach additional pages as necessary

  No fee

Form 70

Created
07/2013

Mediator Report

WORD

PDF

If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form
S-1

Revised
1986

Notice of Third Party Action Employee Carrier

WORD

PDF 

If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form
S-2

Revised
1986

 

Notice of Third Party Action Employee

WORD

PDF

If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form
S-3

Revised
1986

Entitlement to Right of Action

WORD

PDF

If more space is required for any field on the form, please attach additional pages as necessary 

No fee

Form
S-4

Revised
1986

Court Certificate

WORD

PDF

If more space is required for any field on the form, please attach additional pages as necessary

No fee

 back to top 

Self-Insurance Forms

Form 6

Revised
04/2000

Application to Create a Self-Insurance Fund

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$250.00

Form 6A

Created
03/1996

Application for Membership in a Self-Insured Fund

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00

Form 7

Created
03/1996

Application to Individually Self-Insure

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$250.00 plus $100.00 for each subsidiary

Form 7A

Corporate Guaranty

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 8

Revised
07/1996

SC Workers’ Com. Comm. Bond Required of Employer Carrying His On Risk

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 8B

Revised
10/2014

Irrevocable Letter of Credit

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 10

Revised
07/1992

South Carolina Self-Insurance Tax Form
(for calculations, Java scripting must be enabled in Adobe Reader)

 

WORD

PDF 
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 11

Revised
03/1996

Fund Quarterly Financial Report

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

 
 
 

Form 12A
Revised
04/2006

First Report of Injury

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 12M
Revised
05/2006

Annual Minor Medical Report

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 14A
Revised
05/2006

Health Insurance Claim Form

WORD format not available

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 14B
Revised
09/2013

Physician’s Statement

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 15
Revised
01/2014

Temporary Compensation Report

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00 for Section III only

Form 15S
Revised
03/1997

Supplemental Report of Varying Temporary Partial Payments

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 16
Revised
09/2007

Agreement for Permanent Disability Disfigurement Compensation

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00 if filed by Claimant's Attorney

Form 16A
Revised
09/2013

Agreement for Permanent Disability/  Disfigurement Compensation

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

 


WORD

 

 

 PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00 if filed by Claimant's Attorney

Form 17
Revised
01/2014

Receipt of Compensation

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 18
Revised
01/2014

Periodic Report

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 19
Revised
01/2014

Status Report and Compensation Receipt

WORD

  PDF 
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 20
Revised
01/2014

Statement of Earning of Injured Employee

WORD

PDF 
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 24
Revised
09/1990

Application for Lump Sum Award

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00

Form 50
Revised
07/2013

Employee's Notice of Claim and or Request for Hearing

WORD

 

PDF

If more space is required for any field on the form, please attach additional pages as necessary

 

$25.00 for Request for Hearing only

Form 52
Revised
07/2013

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

WORD

PDF
 If more space is required for any field on the form, please attach additional pages as necessary

$25.00 for Request for Hearing only

Form 61
Revised
07/2008

Attorney Fee Petition

WORD

PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form
S-1
Revised
1986

 

Notice of Third Party Action Employee Carrier

WORD

PDF

If more space is required for any field on the form, please attach additional pages as necessary 

No fee

Form
S-2
Revised
1986

Notice of Third Party Action Employee

WORD

PDF 

If more space is required for any field on the form, please attach additional pages as necessary

No fee

 
 
 
Judicial Forms

Form 21

Revised
07/2013

 

Employer's Request for Hearing

WORD

 

  PDF
If more space is required for any field on the form, please attach additional pages as necessary

$25.00

Form 22

Created
07/2013

Claimant's Answer to Request for Hearing

WORD

 PDF
If more space is required for any field on the form, please attach additional pages as necessary

Form 27

Revised
03/2014

Subpoena

WORD

 

  PDF

If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 30

Revised
07/2013

 

Request for Commission Review

WORD

 

  PDF
If more space is required for any field on the form, please attach additional pages as necessary

$150.00

Form 32

Revised
07/2003

Request to Waive Appeal Filing Fee

WORD

 

  PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 33

Revised
07/2006

 

Hearing Postponed

WORD

    PDF

If more space is required for any field on the form, please attach additional pages as necessary

 No fee

Form 51

Revised
07/2013

 

Employer's Answer to Request for Hearing

WORD

 

 PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 53

Revised
07/2013

 

Employer's Answer to Request for Hearing, Death Case

WORD

  PDF
If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 54

Revised
07/2013

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

WORD

 PDF
If more space is required for any field on the form, please attach additional pages as necessary

 $25.00

Form 55

Revised
07/2013

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

WORD

  PDF
If more space is required for any field on the form, please attach additional pages as necessary

 No fee

Form 58

Revised
07/2013

Pre-Hearing Brief

WORD

  PDF
If more space is required for any field on the form, please attach additional pages as necessary

 

No fee

Form 59

Revised
09/1990

Appellant’s Informal Brief

WORD

  PDF
If more space is required for any field on the form, please attach additional pages as necessary

 

No fee

Form 65

Revised
01/1997

Occupational Disease Waiver

WORD

PDF

If more space is required for any field on the form, please attach additional pages as necessary

No fee

Form 70

Created
07/2013

Mediator Report

WORD

PDF

If more space is required for any field on the form, please attach additional pages as necessary

No fee

 
 
 
 

About Filing Fees

There is a $25.00 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