Fill and Sign the 15s South Carolina Workers Compensation Commission Form

In an ongoing period of te mporary partial, when the compensation rate varies from week to week, the employer’s representative shall report the first pa yment on a Form 15 according to R.67 -503. Supplemental payments shall be reported on a Form 15S, to be filed with the document stop ping that period of temporary partial compensation or with the Form 18, which shall be filed six months after the date of injury and each six months thereafter unt il the file is closed. R.67 -503. WCC Form # 15S Rev. 3/97 15S Supplemental Report of Varying Temporary Partial Payments South Carolina Workers’ Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202 -1715 (803) 737 -5723 WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: SSN: Address: City: State: Zip: Home Phone: Work Phone: Employer's Name: Address: City: State: Zip: Insurance Carrier: Preparer’s Name: Law Firm: Prepar er’s Phone #: Date of injury : _______ ___ (m/d/yyyy) Supplemental Report of Varying Temporary Partial Payments From _______ through _______ , Claimant was paid $ _______ per week as temporary partial compensation. The weekly wage before the injury was $ _______ . The weekly wage for this period was $ _______ . From _______ through _____ __, Claimant was paid $ _______ per week as temporary partial compensation. The weekly wage before the injury was $ _______ . The weekly wage for this period was $ _______ . From _____ __ through _______ , Claimant was paid $ _______ per week as temporary partial compensation. The weekly wage before the injury was $ _______ . The weekly wage for this period was $ ____ ___ . From _______ through _______ , Claimant was paid $ _______ per week as temporary partial compensation. The weekly wage before the injury was $ _______ . The weekly wage for this period was $ _______ . From _______ through _______ , Claimant was paid $ _______ per week as temporary partial compensation. The weekly wage before the injury was $ _______ . The weekly wage for this period was $ _______ . From _______ through _______ , Claimant was paid $ _______ per week as temporary partial compensation. The weekly wage before the injury was $ _______ . The weekly wage for this period was $ _______ . From _______ through _______ , Claimant was paid $ _______ per week as temporary partial c ompensation. The weekly wage before the injury was $ _______ . The weekly wage for this period was $ _______ . From _______ through _______ , Claimant was paid $ ____ ___ per week as temporary partial compensation. The weekly wage before the injury was $ _______ . The weekly wage for this period was $ _______ . From _______ through _______ , Claiman t was paid $ _______ per week as temporary partial compensation. The weekly wage before the injury was $ _______ . The weekly wage for this period was $ _______ .