Fill and Sign the Ri Ght of Acti on Form

Sout h Carolina W orkers’ Com pensat ion Com m ission 1333 Main St reet , Suit e 500 P.O. BOX 1715 Columbia, SC 29202-1715 ( 803) 737-5675 I .C. File # : The use of t his form is required under t he provisio ns of t he Sout h Carolina W orkers’ Com pensat ion La w . ENTI TLEM ENT TO RI GHT OF ACTI ON I n t he Workers’ Compensat ion Claim of , Employee , Claimant(s) vs. , Employer , Carrier The undersigned carrier or self -insurer employer a ssumes and assert s herew it h ent it lement t o bring a t hird part y act ion in t he above mat t er against , as def endant ( s) on t he ground t hat t he right of act ion of t he inj ured employee or his surviving Workers’ Compensat i on benef iciary or ( ot her person ent it led t o sue) t o sue t he t hird part y has passed t o t he carrier or self -insurer by st at ut ory assignment f or ( check one) : Failure t o ef f ect a set t lement or t o commence an a ct ion against t he t hird part y w it hin one ( 1) year af t er t he accept ance of liabilit y f or payment of Workers’ Compensat ion by t he carrier or self-insurer employer; Failure t o commence an act ion against t he t hird pa rt y and t here remains t hirt y ( 30) days or less bef ore t ime f or br inging such act ion expires; AND That t he above-named inj ured employee, claimant ( s) and ( ot her person ent it led t o sue) , w ere served w rit t en not ice by cert if ied mail on , , t hat f ailure t o commence an an appropriat e act ion against t he t hird part y w ill operat e as an assignment of t he cause of act i on t o t he Workers’ Compensat io n carrier or self-insurer employer; and t hat t w ent y ( 20) days have passed since t hat not ice of , . Worker s’ Compensat ion Carrier or Self -I nsurer Employer DATED: At t orney f or Carrier or Self -I nsurer Employer W CC Form # S- 3 Rev. 1 9 8 6 S- 3 Ent it lem ent t o Right of Act ion