Fill and Sign the Date of Injury or Illness DOC Templatepdffiller Form

Emplo yer’s representative must complete and file Form 15 with Claims Department within ten days after compensation begins or is terminated. Employer’s representative must serve the Form 15 on the claimant when compensation begins per R.67 - 211 . Employer’s repr esentative must prepare and serve Form 20 within thirty days of beginning compensation per R.67 - 1603 . Employer’s representative must serve per R.67 - 211 two copies of the Form 15 on claimant immediately on termination of compensation with documentation att ached as to the reason for the termination. Injured worker may contest termination of compensation by completing section III of the Form 15 and filing it with Judicial Department. WCC Form # 15 Rev. 01/2014 15 TEMPORARY COMPENS ATION REPORT S outh C arolina 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: Address: City: State: Zip: Home Phone: Work Phone: Employer's Name: Address: City: State: Zip: Insurance Carrier: Preparer’s Name: Law Firm: Preparer ’s Phone #: Date of injury: ____________ (m/d/yyyy) Date of Notice to Employer of Injury: ___________ (m/d/yyyy) I. Payment of Temporary Compensation Check one: Initial period Additional period Corrected compensation rate (choose A, B, or C) A. Temporary Total at the compensation rate of _______ per week. For this period of disability, disability began on _______ (m/d /yyyy) and the date of first payment was _______ (m/d/yyyy) . B. Temporary Partial at the compensation rat e of ____ per week. Note: When the Temporary Partial compensation rate will vary, report the first payment here. Supplement this report throughout the period of Temporary Partial compensation by filing a Form 15S with the Form 18, which shall be filed six months after the date of injury and each six months thereafter until the file is closed. For this period of disability, disability began on (m/d/yyyy), and the date of first payment was (m/d/yyyy) . Calculation of Temporary Partial R ate: Average weekly wage before injury Current weekly wage ________________ = Difference in wages before injury and now x .6667 _____________________________ Temporary Partial Compensation Rate C . Salary in lieu of Temporary Total Partial (choose one) compensation in the amount of per week. For this period of disability, disability began on (m/d/yyyy) and the date of first payment of salary in lieu of temporary compensation was (m/d/yyyy) . THIS SECTION MAY BE USED ONLY WITHIN 150 DAYS AFTER NOTICE TO EMPLOYER OF INJURY. ATTACH DOCUMENTATION AS TO THE REASON OF THE TERMINATION. II. Termination of Temporary Compensation Temporary compensation payments were stopped on (m/d/yyyy) for the following reason: Claimant has returned to work at least 15 days and no temporary partial compensation is due. Claimant agrees he/she is able to return to work and has signed a Form 17 . Based on a good faith investigation, the claim is denied. Reason for denial: Claimant has been released to return to work without restrictions and employment has been offered. Claimant has been rele ased to work at limited duty and employer has provided limited duty work consistent with the terms upon which the Employee has been released. Claimant has refused medical treatment, examination, or evaluation. Note: Benefits must be resu med if claimant accepts the treatment, examination, or evaluation. Additional report must be filed if compensation is resumed. I certify that this form has been served on the claimant per R.67-211. Signature of Claims Administrator Date (m/d/yyyy) III. Notice to Injured Worker or Legal Representative when Temporary Compensation Has Been Stopped: The employer’s representative may stop temporary compensation within 150 days of the date of notice of injury for the above reasons. However, if you believe that the temporary compensation should not have been stopped, you may request a hearing by signing below and returning this form to SCWCC Judicial Department at the address at the top of this form. A hearing will be held within 60 days of receipt of your request to determine if temporary compensation has been properly terminated. MY SIGNATURE BELOW INDICATES THAT I DO NOT AGREE WITH THE TERMINATION OF TEMPORARY COMPENSATION. I REQUEST A HEARING TO DETERMINE WHETHER I AM ENTITLED TO FURTHER TEMPORARY COMPENSATION PAYMENTS. Check one: Form 15(II) Has Has not been received. Signature of Claimant or Legal Representative Date (m/d/yyyy)- $