Fill and Sign the You Are Commanded to Appear Before the above Named Commission at the Place Date and Time Specified below to Form

Serve this form according to R.67-211(C). Refer to R.67-21 1 and R.67-214 for additional information. Procedural questions may be addressed to the Judicial Department at 803-737-5675. WCC Form # 27 Rev. 03/2014 27 SUBPOENA S outh C arolina Workers’ Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202 - 1715 803 - 737 - 567 5 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 #: SUBPOENA To: YOU ARE COMMANDED to appear before the above - named Commission at the place, date and time specified below to testify in the above case. PLACE OF TESTIMONY: ROOM: DATE AND TIME: YOU ARE COMMANDED to appear at the place, date and time specified below to testify at the taking of a deposition in the above case. PLACE OF DEPOSITION: DATE AND TIME: YOU ARE COMMANDED to produce and permit inspection and copying of the following documents or objects in your possession, custody or control at the place, date and time specified below. LIST OF DOCUMENTS: PLACE: DATE AND TIME: YOU ARE COMMANDED to permit inspection of the following premises at the date and time specifi ed below. PREMISES: DATE AND TIME: THIS SUBPOENA SHALL REMAIN IN EFFECT UNTIL YOU ARE GRANTED PERMISSION TO DEPART BY THE COMMISSIONER OR AN OFFICER ACTING ON BEHALF OF THE COMMISSIONER. QUESTIONS CONCERNING THIS SUBPOENA SHOULD BE ADDRESSED TO THE FOLLOWING ISSUING OFFICER. ISSUING OFFICER’S SIGNATURE AND TITLE PHONE NUMBER DATE