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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 #NameDownloadFiling Fee
Form 5Corporate Officer Notice to RejectPDFNo Fee
Form 6Application to Create a Self-Insurance FundPDF$250.00
Form 6AApplication for Membership in a Self-Insured FundPDF$25.00
Form 7Application to Individually Self-InsurePDF$250.00 plus $100.00 for each subsidiary
Form 7ACorporate GuarantyPDFNo fee
Form 8SC Workers’ Com. Comm. Bond Required of Employer Carrying His Own RiskPDFNo fee
Form 8BIrrevocable Letter of CreditPDFNo fee
Form 10South Carolina Self-Insurance Tax Form (for calculations, Java scripting must be enabled in Adobe Reader)PDFNo fee
Form 11Fund Quarterly Financial ReportPDFNo fee
Form 12AFirst Report of InjuryPDFNo fee
Form 12MAnnual Minor Medical ReportPDFNo fee
Form 14AHealth Insurance Claim FormPDFNo fee
Form 14BPhysician’s StatementPDFNo fee
Form 15Temporary Compensation ReportPDF$25.00 for Section III only
Form 15SSupplemental Report of Varying Temporary Partial PaymentsPDFNo fee
Form 16Agreement for Permanent Disability/ Disfigurement CompensationPDF$25.00 if Claimant is represented
Form 16AAgreement for Permanent Disability/ Disfigurement Compensation For injuries occurring after July 1, 2007.PDF$25.00 if Claimant is represented
Form 17Receipt of CompensationPDFNo fee
Form 18Periodic ReportPDFNo fee
Form 19Status Report and Compensation ReceiptPDFNo fee
Form 20Statement of Earning of Injured EmployeePDFNo fee
Form 21Employer’s Request for HearingPDF$25.00
Form 22Claimant’s Answer to Request for A HearingPDFNo fee
Form 24Application for Lump Sum AwardPDF$25.00
Form 27SubpoenaPDFNo fee
Form 30Request for Commission ReviewPDF$150.00
Form 32Request to Waive Appeal Filing FeePDFNo fee
Form 33Hearing PostponedPDFNo fee
Form 38Employer’s Withdrawal of Election to Adopt the South Carolina Workers’ Compensation ActPDFNo fee
Form 39Coverage Coding SheetPDFNo fee
Form 50Employee’s Notice of Claim and or Request for HearingPDF$25.00 for Request for Hearing only
Form 51Employer’s Answer to Request for HearingPDFNo fee
Form 52Employee’s Notice of Claim and/or Request for HearingPDF$25.00 for Request for Hearing only
Form 53Employer’s Answer to Request for Hearing, Death CasePDFNo fee
Form 54Employer’s Notice of Claim and/or Request for HearingPDF$25.00
Form 55Second Injury Fund’s Answer to Employee’s Request for HearingPDFNo fee
Form 58Pre-Hearing BriefPDFNo fee
Form 59Appellant’s Informal BriefPDFNo fee
Form 61Attorney Fee PetitionPDFNo fee
61 OrderAttorney Fee PetitionPDFNo fee
61AAttorney Fee Petition Supplemental InformationPDFNo fee
Form 65Occupational Disease WaiverPDFNo Fee
Form 70 (Effective July 2013)Mediator ReportPDFNo fee
Form S-1Notice of Third Party Action Employee CarrierPDFNo fee
Form S-2Notice of Third Party Action EmployeePDFNo fee
Form S-3Entitlement to Right of ActionPDFNo fee
Form S-4Court CertificatePDFNo 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 #NameDownloadFiling Fee
Form 5Corporate Officer Notice to RejectPDFNo Fee
Form 6Application to Create a Self-Insurance FundPDF$250.00
Form 6AApplication for Membership in a Self-Insured FundPDF$25.00
Form 7Application to Individually Self-InsurePDF$250.00 plus $100.00 for each subsidiary
Form 7ACorporate GuarantyPDFNo fee
Form 8SC Workers’ Com. Comm. Bond Required of Employer Carrying His Own RiskPDFNo fee
Form 8BIrrevocable Letter of CreditPDFNo fee
Form 10South Carolina Self-Insurance Tax Form (for calculations, Java scripting must be enabled in Adobe Reader)PDFNo fee
Form 11Fund Quarterly Financial ReportPDFNo fee
Form 12AFirst Report of InjuryPDFNo fee
Form 12MAnnual Minor Medical ReportPDFNo fee
Form 14AHealth Insurance Claim FormPDFNo fee
Form 14BPhysician’s StatementPDFNo fee
Form 15Temporary Compensation ReportPDF$25.00 for Section III only
Form 15SSupplemental Report of Varying Temporary Partial PaymentsPDFNo fee
Form 16Agreement for Permanent Disability/ Disfigurement CompensationPDF$25.00 if Claimant is represented
Form 16AAgreement for Permanent Disability/ Disfigurement Compensation For injuries occurring after July 1, 2007.PDF$25.00 if Claimant is represented
Form 17Receipt of CompensationPDFNo fee
Form 18Periodic ReportPDFNo fee
Form 19Status Report and Compensation ReceiptPDFNo fee
Form 20Statement of Earning of Injured EmployeePDFNo fee
Form 21Employer’s Request for HearingPDF$25.00
Form 22Claimant’s Answer to Request for A HearingPDFNo fee
Form 24Application for Lump Sum AwardPDF$25.00
Form 27SubpoenaPDFNo fee
Form 30Request for Commission ReviewPDF$150.00
Form 32Request to Waive Appeal Filing FeePDFNo fee
Form 33Hearing PostponedPDFNo fee
Form 38Employer’s Withdrawal of Election to Adopt the South Carolina Workers’ Compensation ActPDFNo fee
Form 39Coverage Coding SheetPDFNo fee
Form 50Employee’s Notice of Claim and or Request for HearingPDF$25.00 for Request for Hearing only
Form 51Employer’s Answer to Request for HearingPDFNo fee
Form 52Employee’s Notice of Claim and/or Request for HearingPDF$25.00 for Request for Hearing only
Form 53Employer’s Answer to Request for Hearing, Death CasePDFNo fee
Form 54Employer’s Notice of Claim and/or Request for HearingPDF$25.00
Form 55Second Injury Fund’s Answer to Employee’s Request for HearingPDFNo fee
Form 58Pre-Hearing BriefPDFNo fee
Form 59Appellant’s Informal BriefPDFNo fee
Form 61Attorney Fee PetitionPDFNo fee
61 OrderAttorney Fee PetitionPDFNo fee
61AAttorney Fee Petition Supplemental InformationPDFNo fee
Form 65Occupational Disease WaiverPDFNo Fee
Form 70 (Effective July 2013)Mediator ReportPDFNo fee
Form S-1Notice of Third Party Action Employee CarrierPDFNo fee
Form S-2Notice of Third Party Action EmployeePDFNo fee
Form S-3Entitlement to Right of ActionPDFNo fee
Form S-4Court CertificatePDFNo 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.