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

Current through Register Vol. 48, No. 6, June 28, 2024
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.