Fill and Sign the Employee Sustained a Compensable Accidental Injury to the Form

Questions regarding this form should be directed to the Judicial Department at 803.737.5675, or judicial@wcc.sc.gov or mediation@wcc.sc.gov. Refer to Regulations 67 - 204 through 67 - 211 and Regulations 601 through 67 - 615 as well as Reg. 67 - 1801. WCC Form # 54 Rev ised 7/13 54 Employer’s Notice of Claim and/or Request for Hearing S outh C arolina Workers’ Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 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: Preparer's Name: Employer's Name: Address: City: State: Zip: Carrier: Preparer’s Phone #: Check applicable claims and complete all blanks. 1. The employee sustained a compensable accidental injury to the (part of the body) on _________ _____ _ (m/d/yyyy) in ________________ _________ ____ (county) , State of _______________ (state). 2. That the Second Injury Fund was put on notice of the claim on _____________ (m/d/yyy). 3. That the carrier concluded the disability claim by Award Agreement on _____________ (m/d/yyy y ) . 4. That the subsequent injury combined with or was aggravated by the below - named permanent impairment under S.C. Code Section 42 - 9 - 400 (d): a. Listed Impairment – (1) – (33) b. (34) (a) c. (34) (b ) 5. a. That the impairment preexisted; b. That the impairment was permanent; and c. That the impairment is a physical condition. 6. That the prior impairment combined with or was aggravated by the subsequent injury. 7. That the combination/aggravation substantially increased the liability of the carrier for: disability medical or both. 8. That the impairment was a hindrance or obstacle to employment or re - employment. 9. a. That the employer has knowledge of the prior impairment; b. That the impairment was unknown to the emplo yee and the employer; or c. That the employee concealed the prior impairment from the employer. 10. That the subsequent injury would no t have occurred “but for” the prior impairment. 11. That the above claim qualifies for reimbursement under S.C. Code Section 42 - 9 - 410 because: 12. Other grounds for claim: Mediation a. Mediation is requ ested 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 delivering a copy to_______________________________________ address__________________________________________________________ on the _________day of _______________20__ ___, by first class postage certified mail personal service. A $25.00 filing fee and updated Form 18 is required. _________________________________________ ______________________________ ____ __________________ Preparer’s Signature Title Email Date