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Coverage Coding Sheet For Attorneys 39 - South Carolina

Coverage Coding Sheet For Attorneys Form. This is a South Carolina form and can be used in Workers Comp .
 Fillable pdf Last Modified 11/19/2013
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State of South Carolina 1333 Main St, Suite 500 P.O. Box 1715 Columbia, S.C. 29202-1715 Tel: (803) 737-6203 Fax: (803) 737-1258 www.wcc.sc.gov Workers' Compensation Commission COVERAGE CODING SHEET FOR ATTORNEYS Today's Date: Claimant's Name: Social Security Number: Date of Accident: Employer's Name: Employer's Address: Employer FEIN: Insured Name: (if different from employer) Carrier Name: Address: Phone Number: Policy Number: Carrier Code: Effective Dates: Coverage located on-line Coverage located by SCWCC No coverage found Attach a copy of this document to all Letters of Representation and/or Forms 50/52 filed with the Workers' Compensation Commission and Insurance Carrier, until a file has been established. Coverage information can be obtained through our website, wcc.sc.gov, via email, coverage@wcc.sc.gov, or by calling the Coverage Division at (803) 737-6203. WCC Form # 39 Revised 6/10 39 COVERAGE CODING SHEET American LegalNet, Inc. www.FormsWorkFlow.com
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