South Carolina Workers' Compensation Forms

Personal Injury Lawyers Representing Charleston & nearby areas of South Carolina

The South Carolina Workers' Compensation Commission offers all of its necessary forms in Word and PDF fillable format on their website at http://www.wcc.sc.gov. For the convenience of our clients, we have provided those exact same workers' compensation forms here on our website. You can download and fill them out or print and complete them manually.

If you have questions or need assistance with any of these forms, please contact the Steinberg Law Firm at 855-270-5760. We highly recommend that you do not attempt to complete these forms without the guidance of an experienced workers' compensation attorney

Form #

Name

Download

Download

Filing Fee

Form 5

Corporate Officer Notice to Reject

WORD

PDF

No fee

Form 6

Application to Create a Self-Insurance Fund

WORD

PDF

$250.00

Form 6A

Application for Membership in a Self-Insured Fund

WORD

PDF

$25.00

Form 7

Application to Individually Self-Insure

WORD

PDF

$250.00 plus $100.00 for each subsidiary

Form 7A

Corporate Guaranty

WORD

PDF

No fee

Form 8

SC Workers’ Com. Comm. Bond Required of Employer Carrying His Own Risk

WORD

PDF

No fee

 

Form 8B

Irrevocable Letter of Credit

WORD

PDF

No fee

Form 10

South Carolina Self-Insurance Tax Form
(for calculations, Java scripting must be enabled in Adobe Reader)

WORD

PDF

No fee

 

Form 11

Fund Quarterly Financial Report

WORD

PDF 

No fee

Form 12A

First Report of Injury

WORD

PDF

No fee

Form 12M

Annual Minor
Medical Report

WORD

PDF

No fee

Form 14A

Health Insurance Claim Form

WORD format not available

PDF

No fee

Form 14B

Physician’s Statement

WORD

PDF

No fee

Form 15

Temporary Compensation Report

WORD

PDF

$25.00 for Section III only

Form 15S

Supplemental Report of Varying Temporary Partial Payments

WORD

PDF

No fee

Form 16

Agreement for Permanent Disability/ Disfigurement Compensation

WORD

PDF

$25.00 if Claimant is represented

Form 16A

Agreement for Permanent Disability/ Disfigurement Compensation
For injuries occurring after July 1, 2007.

WORD

PDF

$25.00 if Claimant is represented

Form 17

Receipt of Compensation

WORD

PDF

No fee

Form 18

Periodic Report

WORD

PDF

No fee

Form 19

Status Report and Compensation Receipt

WORD

PDF

No fee

Form 20

Statement of Earning of Injured Employee

WORD

 PDF

No fee

Form 21

Employer's Request for Hearing

WORD

PDF

$25.00

Form 22

Claimant's Answer to Request for A Hearing

WORD

PDF

No fee

Form 24

Application for Lump Sum Award

WORD

PDF

$25.00

Form 27

Subpoena

WORD

PDF

No fee

Form 30

Request for Commission Review

WORD

PDF

$150.00

Form 32

Request to Waive Appeal Filing Fee

WORD

PDF

No fee

Form 33

Hearing Postponed

WORD

 PDF

No fee

Form 38

Employer’s Withdrawal of Election to Adopt the South Carolina Workers’ Compensation Act

WORD

PDF

No fee

Form 39

Coverage Coding Sheet

WORD

PDF

No Fee

Form 50

Employee's Notice of Claim and or Request for Hearing

WORD

PDF

$25.00 for Request for Hearing only

Form 51

Employer's Answer to Request for Hearing

WORD

PDF 

No fee

Form 52

Employee's Notice of Claim and/or Request for Hearing

WORD

PDF

$25.00 for Request for Hearing only

Form 53

Employer's Answer to Request for Hearing, Death Case

WORD

PDF

No fee

Form 54

Employer's Notice of Claim and/or Request for Hearing

WORD

PDF

$25.00

Form 55

Second Injury Fund's Answer to Employee's Request for Hearing

WORD

PDF

No fee

Form 58

Pre-Hearing Brief

WORD

PDF

No fee

Form 59

Appellant’s Informal Brief

WORD

PDF

No fee

Form 61

Attorney Fee Petition

WORD

PDF

No fee

61 Order

Attorney Fee Petition

WORD

PDF

No fee

61A

Attorney Fee Petition Supplemental Information

WORD

PDF

No fee

Form 65

Occupational Disease Waiver

WORD

PDF

  No fee

Form 70

(Effective July 2013)

Mediator Report

WORD

PDF

No fee

Form S-1

Notice of Third Party Action Employee Carrier

WORD

PDF

No fee

Form S-2

Notice of Third Party Action Employee

WORD

PDF

No fee

Form S-3

Entitlement to Right of Action

WORD

PDF 

No fee

Form S-4

Court Certificate

WORD

PDF

No fee