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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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(New - Effective July 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

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

Subpoena

WORD

 

PDF

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

No fee

Form 30

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

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

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

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


 

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

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

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

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

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

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

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

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

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

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

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

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

(New - Effective July 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(New - Effective July 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

Subpoena

WORD

 

  PDF

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

No fee

Form 30

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

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

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

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

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

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

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

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

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

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

(New - Effective July 2013)

Mediator Report

WORD

PDF

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

No fee

 
 
 
 

 

SC Trading Partner Profile

PDF

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

 

SC WCC EDI Requirements Table

PDF

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

 

 

 

About Filing Fees

There is a $25.00 fee for the following:

  • Clinchers, Settlements, Motions
  • Letters, motions, etc. requesting a dependency hearing
  • Third Party Settlements

 The following are excluded from fees:

  • Requests for informal conferences and approval of Form 16 as a result of the viewing
  • Consent Orders/Motions/Petitions adding or deleting attorneys, protection orders for vacation, or to appoint guardian ad litems
  • Form 21, Sec II (b), Request to certify a Form 17
  • Hearings set on the Commission’s Motions due to no agreement being reached at the informal conference
  • Consent Orders that DO NOT require a hearing or a decision of a commissioner.  A consent order which operates as a final settlement is considered to be a clincher and DOES require a fee.
  • If a filing is AMENDED, the amended form must be clearly marked as AMENDED, filed with the Commission and served on all parties.  However, if the original document filed was exempt from the fee and you amend the document to file for relief that is not exempt from the fee, then a new form and fee must be filed.