Fill and Sign the South Carolina Workers Compensation Form

South Carolina Workers’ Compensation Commission 1333 Main Street, Suite 500 ● Post Office Box 1715 Columbia, South Carolina 29202- 1715 (803) 737- 5723 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 death benefits is made based on the following grounds: The Claimant is (relationship to employee) of (employee’s nam e) 1 . The employee sustained an accidental injury to the ______________________________________________ (Part of Body Hurt) on _____________ ( m/d/yyyy) in ________________ County, State of _______ . 2. Both the employee and the employer were subject to the South Carolina Workers’ Compensation Act at the tim e of injury. 3. The relationship of employer and employee existed at the time of injury. 4. At the time of the injury the employee was performing services arising out of and i n the course of employment. 5. Notice of the accidental injury was given to the employer on _____________ (m/d/yyyy ) in the following manner: 6. Due to injury, the employee received medical examination and treatment wh ich remains unpaid by the employer. 7. Due to injury, the employee lost compensable time from work and wages for the pe riods of: 8. The employee died on (m/d/yyyy) as a result of the accidental injury, and death compensation is claimed. 9. At the time of the injury, the employee was paid weekly wages of $___ _____. The claimant demands an accounting of days worked and wages earned as provided by law. 10. Further grounds of claim: 11. Appropriate benefits as provided in the Act for the above grounds and other relief as the Workers’ C ompensation Commission may direct as just and proper. 12a . I am filing a claim. I am not requesting a hearing at this time. 12b . I am requesting a hearing. A $25 fee is required. Mediation a. Mediation is req uested to be ordered pursuant to Reg. 67-1801 B. b. Mediation 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 deliv ering a copy to_______________________________________ address______________________________________________ ____________ on the _________day of _______________20____ , by first class postage certified mail personal service. I verify the contents of this form are accurate and true to the best o f my knowledge. _________________________________________ ______________________________ ____ _____________ _____ Preparer’s Signature Title Email Date Questions about the use of this form should be directed to the Judicial Department at 80 3.757.5675 or judicial @wcc.sc.gov or mediation@wcc.sc.gov. Refer to Regulations 67-205 through 67-211, 67-216 , Regulations 67-601 through 67-615 and; Regulations 67-901 through 67 -905 well as Reg. 67-1801. WCC Form # 52 Revised 7/13 52 Employee’s Notice of Claim and/or Request for Hearing, Death Case