1. 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.

2. 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. (1) Form S-1, Notice of Third Party Action, Employer;
   2. (2) Form S-2, Notice of Third Party Action, Employee;
   3. (3) Form S-3, Entitlement to Right of Action;
   4. (4) Form S-4, Court Certificate;
   5. (5) Form 2, Employer’s Notice of Being Subject to the Act;
   6. (6) Form 5, Corporate Officer Notice to Reject;
   7. (7) Form 6, Application to Create a Self-Insurance Fund;
   8. (8) Form 6A, Application for Membership in a Self-Insurance Fund;
   9. (9) Form 7, Application to Individually Self-Insure;
   10. (10) Form 7A, Corporate Guaranty;
   11. (11) Form 8, Proof of Compliance, Surety Bond;
   12. (12) Form 8A, Proof of Compliance, Securities Pledge;
   13. (13) Form 8B, Proof of Compliance, Memorandum of Understanding, and Irrevocable Letter of Credit;
   14. (14) Form 8C, Proof of Compliance, Excess Insurance;
   15. (15) Form 9, Certificate for Self-Insurance;
   16. (16) Form 10, Self Insurance Tax Return;
   17. (17) Form 11, Self Insurer’s Quarterly Financial Report;
   18. (18) Form 11A, Self Insurer’s Annual Financial Report;
   19. (19) Form 12A, Employer’s First Report of Injury (ACORD 4);
   20. (20) Form 12M, Annual Minor Medical Report;
   21. (21) Form 14A, Health Insurance Claim Form (HCFA-1500);
   22. (22) Form 14B, Physician’s Statement;
   23. (23) Form 15, Temporary Compensation Report;
   24. (24) Form 15S, Supplemental Report of Varying Temporary Partial Payments;
   25. (25) Form 16, Agreement for Permanent Disability/Disfigurement Compensation (prior to July 1, 2007);
   26. (26) Form 16A, Agreement for Permanent Disability/Disfigurement Compensation (after July 1, 2007);
   27. (27) Form 17, Receipt of Compensation;
   28. (28) Form 18, Periodic Report;
   29. (29) Form 19, Status Report and Compensation Receipt;
   30. (30) Form 20, Statement of Earnings of Injured Employee;
   31. (31) Form 21, Employer’s Request for Hearing;
   32. (32) Form 24, Application for Lump Sum Award;
   33. (33) Form 27, Subpoena;
   34. (34) Form 30, Request for Commission Review;
   35. (35) Form 31, Notice of Review Hearing;
   36. (36) Form 32, Request to Waive Appeal Filing Fee;
   37. (37) Form 36, Medical Fee Approval;
   38. (38) Form 38, Employer’s Withdrawal of Election to Adopt the South Carolina Workers’ Compensation Act;
   39. (39) Form 39, Coverage Coding Form;
   40. (40) Form 50, Employee’s Notice of Claim and/or Request for Hearing;
   41. (41) Form 51, Employer’s Answer to Request for Hearing;
   42. (42) Form 52, Employee’s Notice of Claim and/or Request for Hearing, Death Case;
   43. (43) Form 53, Employer’s Answer to Request for Hearing, Death Case;
   44. (44) Form 54, Employer’s Notice of Claim and/or Request for Hearing;
   45. (45) Form 55, Second Injury Fund’s Answer to Employer’s Request for Hearing;
   46. (46) Form 58, Pre-hearing Brief;
   47. (47) Form 59, Appellant’s Informal Brief;
   48. (48) Form 61, Attorney Fee Petition;
   49. (49) Form 65, Waiver of Claim Involving an Occupational Disease;
   50. (50) Second Injury Fund Form 1, Agreement to Reimburse Compensation;
   51. (51) Second Injury Fund Form 2, Reimbursement Request;
   52. (52) Second Injury Fund Form 3, Employer’s Notice of Claim for Reimbursement from Second Injury Fund;
   53. (53) Second Injury Fund Form 4, Medical Information Request.

HISTORY: 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.