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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