Fill and Sign the Your Workers Compensation Policy Guide South Carolina Form

A. Total Wages Paid 1. Check Applicable Method: Date of injury: month day year Report of earnings of injured employee based on four completed quarters. Report of earnings of injured employee who did not complete four quarters based on actual time worked. Report of earnings of similar employee. Injured employee did not work sufficient time before alleged injury. Hire Date: Report of earnings of injured employee based on alternative method because Form 20 results in a compensation rate that is not fair and just. (Attach documentation to show how average weekly wage and compensation rate were calculated.) 2. List total wages paid as reported to Employment Security Commission on the Employer Quarterly Contribution and Wage Reports during thefour quarters immediately preceding the quarter in which the injury occurred. Do not include the quarter during which the injury occurred. Ending Date Total Wages Paid Quarter 1st 2nd 3rd Total Paid 4th 2. 3. 3. List total value of other allowances of any character made in lieu of wages during four quarters above. TOTAL WAGES PAID: 4. 4. Add lines 2 and 3. 5. List total number of weeks paid to employee during the four quarters immediately preceding the quarter 5. in which the injury occurred. B. Average Weekly Wage 6. To calculate average weekly wage, divide total wages (line 4) by total weeks paid (line 5). AVERAGE WEEKLY WAGE: 6. C. Compensation Rate 7. The general rule for calculating the compensation rate is to multiply average weekly wage (line 6) by .6667.Estimate compensation rate by multiplying average weekly wage (line 6) by .6667. See part 8 below to determine the actual compensation rate. 7. 8. The compensation rate is as follows (choose one): When average weekly wage (line 6) is less than $75.00, the compensation rate is the average weekly wage. Enter average weekly wage on line 8. When the estimated compensation rate (line 7) is less than $75.00 and average weekly wage (line 6) is more than $75.00, the compensation rate is $75.00. Enter $75.00 on line 8. When the estimated compensation rate (line 7) is more than the maximum compensation rate for the year in which the injury occurred, enter the maximum compensation rate for the year in which the injury occurred on line-8. Employee is within the exceptions listed in S.C. Code Ann. Section 42-7-65. List applicable exception here and enter appropriate compensation rate on line 8- The calculated compensation rate (line 7) applies. Enter amount from line 7 on line 8. WEEKLY COMPENSATION RATE: 8. Employees representative shall prepare a Form 20 and serve per R.67-211 a copy on the claimant within thirty days of beginning temporary com- gross pay before taxes and pensation. See R.67-1603 when no temporary compensation is paid. NOTE: Average weekly wage represents averageother deductions. WHEN THE CLAIMANT DOES NOT AGREE WITH THE COMPENSATION RATE ONLINE 8, HE OR SHE SHOULD CONTACTTHE EMPLOYER'S REPRESENTATIVE TO TRY TO REACH AN AGREEMENT AS TO THE COMPENSATION RATE. IF NO AGREEMENT CANBE REACHED THE CLAIMANT SHOULD CONTACT THE CLAIMS DEPARTMENT AT (803)737-5723. STATEMENT OF EARNINGS OF INJURED EMPLOYEE REV. DATE 3/97 WCC FORM # 20 20 South Carolina Workers' Compensation Commission P.O. Box 1715 1612 Marion Street Columbia, South Carolina 29202-1715 (803)737-5700 WCC File # Carrier File # Carrier Code # Employer FEIN Claimant's Name SSN Employer's Name State Address Zip City Zip State City Address Insurance Carrier Work Phone # Home Phone # Phone # Preparer's Name $10,000.00 $10,000.00 $3,000.00 $2,000.00 $25,000.00 $2,000.00 $27,000.00 45 $600.00 $400.02