South Carolina Code of Regulations
Chapter 67 - SOUTH CAROLINA WORKERS' COMPENSATION COMMISSION
Article 2 - GENERAL
Section 67-203 - Official Forms and Documents

Universal Citation: SC Code Regs 67-203

Current through Register Vol. 47, No. 12, December 22, 2023

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.

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.

Disclaimer: These regulations may not be the most recent version. South Carolina may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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