Current through Register Vol. 48, No. 07, July 26, 2024
Section 67-203 - Official Forms and DocumentsA. 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;(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.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.