South Carolina Workers’ Compensation Forms

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 843-720-2800. We highly recommend that you do not attempt to complete these forms without the guidance of an experienced workers’ compensation attorney.

Form # Name Download Filing Fee
Form 5 Corporate Officer Notice to Reject PDF No Fee
Form 6 Application to Create a Self-Insurance Fund PDF $250.00
Form 6A Application for Membership in a Self-Insured Fund PDF $25.00
Form 7 Application to Individually Self-Insure PDF $250.00 plus $100.00 for each subsidiary
Form 7A Corporate Guaranty PDF No fee
Form 8 SC Workers’ Com. Comm. Bond Required of Employer Carrying His Own Risk PDF No fee
Form 8B Irrevocable Letter of Credit PDF No fee
Form 10 South Carolina Self-Insurance Tax Form (for calculations, Java scripting must be enabled in Adobe Reader) PDF No fee
Form 11 Fund Quarterly Financial Report PDF No fee
Form 12A First Report of Injury PDF No fee
Form 12M Annual Minor Medical Report PDF No fee
Form 14A Health Insurance Claim Form PDF No fee
Form 14B Physician’s Statement PDF No fee
Form 15 Temporary Compensation Report PDF $25.00 for Section III only
Form 15S Supplemental Report of Varying Temporary Partial Payments PDF No fee
Form 16 Agreement for Permanent Disability/ Disfigurement Compensation PDF $25.00 if Claimant is represented
Form 16A Agreement for Permanent Disability/ Disfigurement Compensation For injuries occurring after July 1, 2007. PDF $25.00 if Claimant is represented
Form 17 Receipt of Compensation PDF No fee
Form 18 Periodic Report PDF No fee
Form 19 Status Report and Compensation Receipt PDF No fee
Form 20 Statement of Earning of Injured Employee PDF No fee
Form 21 Employer’s Request for Hearing PDF $25.00
Form 22 Claimant’s Answer to Request for A Hearing PDF No fee
Form 24 Application for Lump Sum Award PDF $25.00
Form 27 Subpoena PDF No fee
Form 30 Request for Commission Review PDF $150.00
Form 32 Request to Waive Appeal Filing Fee PDF No fee
Form 33 Hearing Postponed PDF No fee
Form 38 Employer’s Withdrawal of Election to Adopt the South Carolina Workers’ Compensation Act PDF No fee
Form 39 Coverage Coding Sheet PDF No fee
Form 50 Employee’s Notice of Claim and or Request for Hearing PDF $25.00 for Request for Hearing only
Form 51 Employer’s Answer to Request for Hearing PDF No fee
Form 52 Employee’s Notice of Claim and/or Request for Hearing PDF $25.00 for Request for Hearing only
Form 53 Employer’s Answer to Request for Hearing, Death Case PDF No fee
Form 54 Employer’s Notice of Claim and/or Request for Hearing PDF $25.00
Form 55 Second Injury Fund’s Answer to Employee’s Request for Hearing PDF No fee
Form 58 Pre-Hearing Brief PDF No fee
Form 59 Appellant’s Informal Brief PDF No fee
Form 61 Attorney Fee Petition PDF No fee
61 Order Attorney Fee Petition PDF No fee
61A Attorney Fee Petition Supplemental Information PDF No fee
Form 65 Occupational Disease Waiver PDF No Fee
Form 70 (Effective July 2013) Mediator Report PDF No fee
Form S-1 Notice of Third Party Action Employee Carrier PDF No fee
Form S-2 Notice of Third Party Action Employee PDF No fee
Form S-3 Entitlement to Right of Action PDF No fee
Form S-4 Court Certificate PDF No fee

RESULTS

WE HAVE RECOVERED OVER $500 MILLION FOR CLIENTS IN THE LAST 10 YEARS, INCLUDING:
$2,750,000 in a product defect case, scissor lift malfunction.

South Carolina Workers’ Compensation Forms

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 843-720-2800. We highly recommend that you do not attempt to complete these forms without the guidance of an experienced workers’ compensation attorney.

Form # Name Download Filing Fee
Form 5 Corporate Officer Notice to Reject PDF No Fee
Form 6 Application to Create a Self-Insurance Fund PDF $250.00
Form 6A Application for Membership in a Self-Insured Fund PDF $25.00
Form 7 Application to Individually Self-Insure PDF $250.00 plus $100.00 for each subsidiary
Form 7A Corporate Guaranty PDF No fee
Form 8 SC Workers’ Com. Comm. Bond Required of Employer Carrying His Own Risk PDF No fee
Form 8B Irrevocable Letter of Credit PDF No fee
Form 10 South Carolina Self-Insurance Tax Form (for calculations, Java scripting must be enabled in Adobe Reader) PDF No fee
Form 11 Fund Quarterly Financial Report PDF No fee
Form 12A First Report of Injury PDF No fee
Form 12M Annual Minor Medical Report PDF No fee
Form 14A Health Insurance Claim Form PDF No fee
Form 14B Physician’s Statement PDF No fee
Form 15 Temporary Compensation Report PDF $25.00 for Section III only
Form 15S Supplemental Report of Varying Temporary Partial Payments PDF No fee
Form 16 Agreement for Permanent Disability/ Disfigurement Compensation PDF $25.00 if Claimant is represented
Form 16A Agreement for Permanent Disability/ Disfigurement Compensation For injuries occurring after July 1, 2007. PDF $25.00 if Claimant is represented
Form 17 Receipt of Compensation PDF No fee
Form 18 Periodic Report PDF No fee
Form 19 Status Report and Compensation Receipt PDF No fee
Form 20 Statement of Earning of Injured Employee PDF No fee
Form 21 Employer’s Request for Hearing PDF $25.00
Form 22 Claimant’s Answer to Request for A Hearing PDF No fee
Form 24 Application for Lump Sum Award PDF $25.00
Form 27 Subpoena PDF No fee
Form 30 Request for Commission Review PDF $150.00
Form 32 Request to Waive Appeal Filing Fee PDF No fee
Form 33 Hearing Postponed PDF No fee
Form 38 Employer’s Withdrawal of Election to Adopt the South Carolina Workers’ Compensation Act PDF No fee
Form 39 Coverage Coding Sheet PDF No fee
Form 50 Employee’s Notice of Claim and or Request for Hearing PDF $25.00 for Request for Hearing only
Form 51 Employer’s Answer to Request for Hearing PDF No fee
Form 52 Employee’s Notice of Claim and/or Request for Hearing PDF $25.00 for Request for Hearing only
Form 53 Employer’s Answer to Request for Hearing, Death Case PDF No fee
Form 54 Employer’s Notice of Claim and/or Request for Hearing PDF $25.00
Form 55 Second Injury Fund’s Answer to Employee’s Request for Hearing PDF No fee
Form 58 Pre-Hearing Brief PDF No fee
Form 59 Appellant’s Informal Brief PDF No fee
Form 61 Attorney Fee Petition PDF No fee
61 Order Attorney Fee Petition PDF No fee
61A Attorney Fee Petition Supplemental Information PDF No fee
Form 65 Occupational Disease Waiver PDF No Fee
Form 70 (Effective July 2013) Mediator Report PDF No fee
Form S-1 Notice of Third Party Action Employee Carrier PDF No fee
Form S-2 Notice of Third Party Action Employee PDF No fee
Form S-3 Entitlement to Right of Action PDF No fee
Form S-4 Court Certificate PDF No fee

RESULTS

WE HAVE RECOVERED OVER $500 MILLION FOR CLIENTS IN THE LAST 10 YEARS, INCLUDING:
$2,750,000 in a product defect case, scissor lift malfunction.

What Our Clients Say About Us

I am very pleased with my experience

I have, and will continue to recommend The Steinberg Law Firm. They have worked very hard on my behalf.

It is hard to really put in writing how much Tom was there for me

He really did such an unbelievable job. Even when the settlement was made, he returned a text with a call to share in the joy over another medical event we were going through, that had a great outcome. Yes, they really do care.

I would highly recommend them

Enjoyed the fact that every time I called, someone called me back. It made me feel like my case mattered, and that I mattered. They answered all of my questions and concerns in a timely manner.

They will go the extra mile for you

David Pearlman and his staff did an exceptional job on my claim. Mr. Pearlman was honest, patient and steered me in the right direction. A’Riel was always nice and very helpful. I would recommend them to everyone.

I would never seek help from any other Firm!

The lawyers and their staff are very professional, caring about your situation! They are one of a kind!Get this Firm behind you and you will never be sorry!

It was a pleasure working with Steven Goldberg and his staff

They were courteous and professional. They maintained regular contact for status reports on my case and provided needed documentation on a timely basis. I would recommend this firm.