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Fill and Sign the Use of This Form is Required under the Provisions of the South Carolina Workers Compensation Law

Fill and Sign the Use of This Form is Required under the Provisions of the South Carolina Workers Compensation Law

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South Carolina Workers’ Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5675 I.C. File #: The use of this form is required under the provisions of the South Carolina Workers’ Compensation Law. NOTICE OF THIRD PARTY ACTION EMPLOYEE In the Workers’ Compensation Claim of , Employee , Claimant(s) vs. , Employer , Carrier TO THE SOUTH CAROLINA WORKERS’ COMPENSATION COMMISSION and the above-named Carrier or Self-Insurer Employer: PLEASE TAKE NOTICE that an action has been commenced against as defendant(s) in the Court of County of and State of under date of , . Employee or Surviving Workers’ Compensation Beneficiary DATED: Attorney for Employee or Surviving Workers’ Compensation Beneficiary A copy of this form must be served upon the South Carolina Workers’ Compensation Co mmission, the Workers’ Compensation carrier or self-insurer employer by personal service, registered or certified mail within thirty ( 30) days after third party action commenced; and, the third party action must be commenced within one (1) year after employer-carrier accepts liability for or makes payment of compensation as provided in the Workers’ Compensa tion Law. WCC Form # S-2 Rev. 1986 S-2 Notice of Third Party Action Employee

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