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The Official Web Site of the State of South Carolina

Self-Insurance Forms

The South Carolina Workers’ Compensation Commission offers the following forms applicable to self-insurance procedures. 

If you require assistance, please contact the Self-Insurance Division

Self-Insurance Division
Telephone: 803-737-5706
Fax: 803-737-1258
self-insurance@wcc.sc.gov

 

6

Application to Create a Self-Insurance Fund

PDF

Doc

$250.00

6A

Application for Membership in a Self-Insured Fund

PDF

 

$25.00

7

Application to Individually Self-Insure

PDF

Doc

$250.00 plus $100.00 for each subsidiary

7A

Corporate Guaranty

PDF

Doc

No fee

8

SC Workers’ Compensation Commission Bond Required of
Employer Carrying His Own Risk

PDF

Doc

No fee

8B

Irrevocable Letter of Credit

PDF

Doc

No fee

10

South Carolina Self-Insurance Tax Form

PDF

 

No fee

11

Fund Quarterly Financial Report

PDF

Doc

No fee