Fill and Sign the Form 58 South Carolina Workers Compensation Commission

So uth Caroli na Workers’ Compensation Commission 1333 Main Street, Suite 500 ● Post Office Box 1715 Columbia, South Carolina 29202-1715 (803) 737-5 675 www.wcc.sc.gov 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: Preparer’s Phone #: A claim for workers’ compensation benefits is made based on the following grounds: Date of Injury or Illness: ____________ Injury Illness Repetitive Trauma Occupational Disease Physical Brain Injury Concurrent Jurisdiction 1 . 2. The claimant sustained an injury to _________________________________ (Part(s) of Body Injured) on ________________ (Month/Day/Year) in ________ ___ county, s tate of _______ . Body part (s) affected are: _____ _______________________________________________________________________ Briefly describe how the accident occurred. ________________________________________________________________________________________________ 3 . Bo th the claimant and the e mployer were subject to the South Carolina Workers’ Compensation Act at the time of injury. 4 . The relationship of employer and employee existed at the time of injury. 5 . At the time of the injury the c laimant was performing services arising out of and in the course of employm ent. S . Notice of the acci dental injury was given to the E mployer on ____________ (Month/Day/ Year) in the following mannerW ___ _____________________________________________________________________________________________________________________________ ____ 7 . Due to injury, the c laimant is in need of (check one): (a) medical examination and treatment for: _____________________________________________________________________________________________ (b) additional medical examination and treatment for: ____________________________________________________________________________________ 8 . Due to injury, the c laimant requests temporary total disability benefits because of lost compensable time from work and wages for the period of: 9 . Due to the injury, the C laimant has permanent disability of the following nature and extent (check one): (1) General DisabilityW Total Partial (2) Specific Disability: Total Partial (3) Wage Loss 9 a. A determination of permanent disability is premature at this time. 10 . Due to the injury, the C laimant has a serious bod ily disfigurement consisting of: 10a. At the time of the injury, the C laimant was paid weekly wages of $ _________ , and demands accounting of days worked and wages earned as provided by law. 10b. Give names and addresses of all employers for whom the C laimant has worked since the date of the accident: 11. Further grounds or unusual aspects of claimW 11 a . List names and addresses of all physicians or other medical specialist s who have seen or treated the C laimant as a result of the accident: 11 b . To the best of your knowledge, did you have any prior permanent disability? If yes, describe: 12. Appropriate benefits as provided in the Act for the above grounds and other relief as the Workers’ Compensation Commission ma y direct as just and proper. 13a. I am filing a claim. I am not requesting a hearing at this time. 14. Estimated time needed for hearing: _____________ 13b. I am requesting a hearing. A $25 fee is required. Mediation a.Mediation is requested to be ordered pursuant to Reg. 67-1801 B. b. Mediat io n is required pursuant to Reg. 67-1802. c. Mediation is requested by consent of the Parties pursuant to Reg. 67-1803. d. Mediation has been conducted by a duly qualified mediator and resulted in an impasse. Questions regarding mediation may be submitted to mediation@wcc.sc.gov . I certify I have served this document pursuant to Reg. 67-211 by delivering a copy to______________________________________ _ address__________________________ ___ on the _______day of ___________20____ ,by first class postage certified mail personal service. I verify the c ont ents of this form are accurate and true to the best of my knowledge. __________________________________ ______________________ __________________________ ____________________ Preparer’s Signature Title Email Date Questions about the use of this form should be directed to the Claims Department at 803.737. 5723. Refer to Regulations 67 - 204 through 67 - 211 and Regulations 67 - 601 through 67 - 615 as well as Reg. 67 - 1801. WCC Form # 5 0 Revised 7/13 5 0 Employe e ’s Notice of Claim and/or Request for He aring