S.C. Code Regs. 67-203 - Official Forms and Documents

A. The Commission prepares and approves all required forms. A person shall use a Commission form and shall not substitute another document for a form. Reproduction of a form the same size is permitted, provided content is not altered.

B. Commission forms are available on the web site. The Commission supplies at a reasonable charge, upon written request to the Commission's Mail Room, the following forms.

(1) Form S-1, Notice of Third Party Action, Employer;

(2) Form S-2, Notice of Third Party Action, Employee;

(3) Form S-3, Entitlement to Right of Action;

(4) Form S-4, Court Certificate;

(5) Form 2, Employer's Notice of Being Subject to the Act;

(6) Form 5, Corporate Officer Notice to Reject;

(7) Form 6, Application to Create a Self-Insurance Fund;

(8) Form 6A, Application for Membership in a Self-Insurance Fund;

(9) Form 7, Application to Individually Self-Insure;

(10) Form 7A, Corporate Guaranty;

(11) Form 8, Proof of Compliance, Surety Bond;

(12) Form 8A, Proof of Compliance, Securities Pledge;

(13) Form 8B, Proof of Compliance, Memorandum of Understanding, and Irrevocable Letter of Credit;

(14) Form 8C, Proof of Compliance, Excess Insurance;

(15) Form 9, Certificate for Self-Insurance;

(16) Form 10, Self Insurance Tax Return;

(17) Form 11, Self Insurer's Quarterly Financial Report;

(18) Form 11A, Self Insurer's Annual Financial Report;

(19) Form 12A, Employer's First Report of Injury (ACORD 4);

(20) Form 12M, Annual Minor Medical Report;

(21) Form 14A, Health Insurance Claim Form (HCFA-1500);

(22) Form 14B, Physician's Statement;

(23) Form 15, Temporary Compensation Report;

(24) Form 15S, Supplemental Report of Varying Temporary Partial Payments;

(25) Form 16, Agreement for Permanent Disability/Disfigurement Compensation (prior to July 1, 2007);

(26) Form 16A, Agreement for Permanent Disability/Disfigurement Compensation (after July 1, 2007);

(27) Form 17, Receipt of Compensation;

(28) Form 18, Periodic Report;

(29) Form 19, Status Report and Compensation Receipt;

(30) Form 20, Statement of Earnings of Injured Employee;

(31) Form 21, Employer's Request for Hearing;

(32) Form 24, Application for Lump Sum Award;

(33) Form 27, Subpoena;

(34) Form 30, Request for Commission Review;

(35) Form 31, Notice of Review Hearing;

(36) Form 32, Request to Waive Appeal Filing Fee;

(37) Form 36, Medical Fee Approval;

(38) Form 38, Employer's Withdrawal of Election to Adopt the South Carolina Workers' Compensation Act;

(39) Form 39, Coverage Coding Form;

(40) Form 50, Employee's Notice of Claim and/or Request for Hearing;

(41) Form 51, Employer's Answer to Request for Hearing;

(42) Form 52, Employee's Notice of Claim and/or Request for Hearing, Death Case;

(43) Form 53, Employer's Answer to Request for Hearing, Death Case;

(44) Form 54, Employer's Notice of Claim and/or Request for Hearing;

(45) Form 55, Second Injury Fund's Answer to Employer's Request for Hearing;

(46) Form 58, Pre-hearing Brief;

(47) Form 59, Appellant's Informal Brief;

(48) Form 61, Attorney Fee Petition;

(49) Form 65, Waiver of Claim Involving an Occupational Disease;

(50) Second Injury Fund Form 1, Agreement to Reimburse Compensation;

(51) Second Injury Fund Form 2, Reimbursement Request;

(52) Second Injury Fund Form 3, Employer's Notice of Claim for Reimbursement from Second Injury Fund;

(53) Second Injury Fund Form 4, Medical Information Request.

Notes

S.C. Code Regs. 67-203

Amended by State Register Volume 16, Issue No. 4, eff April 24, 1992; State Register Volume 21, Issue No. 4, eff April 25, 1997; State Register Volume 34, Issue No. 2, eff February 26, 2010.