South Carolina > Workers Comp
Employees Notice Of Claim And Or Request For Hearing - Death Case 52 - South Carolina
| Employees Notice Of Claim And Or Request For Hearing - Death Case Form. This is a South Carolina form and can be used in Workers Comp . |
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WCC File #: South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 Post Office Box 1715 Columbia, South Carolina 29202-1715 (803) 737-5723 Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: Address: SSN: - - Employer's Name: Address: City: State: Zip: City: - State: Zip: Home Phone: ( ) - Work Phone: ( ) Insurance Carrier: Preparer's Name: Law Firm: Preparer's Phone #: ( ) - Complete each information blank. To request a hearing, check Box 12b., indicate the kinds of benefits claimed by checking the box(es) at Lines 6, 7 and 8 and file this form in duplicate. A claim for workers' compensation benefits is made based on the following grounds: The claimant is (relationship to employee) of (employee's name) 1. The employee sustained an accidental injury to the . (Part of Body Hurt) on (Month Day Year) in County, State of 2. 3. 4. 5. Both the employee and the employer were subject to the South Carolina Workers' Compensation Act at the time of injury. The relationship of employer and employee existed at the time of injury. At the time of the injury the employee was performing services arising out of and in the course of employment. Notice of the accidental injury was given to the employer on (Month Day Year) in the following manner: 6. Due to injury, the employee received medical examination and treatment which remains unpaid by the employer. 7. 8. Due to injury, the employee lost compensable time from work and wages for the periods of: The employee died on compensation is claimed. as a result of the accidental injury, and death (Month Day Year) 9. At the time of the injury, the employee was paid weekly wages of $ and wages earned as provided by law. . The claimant demands an accounting of days worked 10. 11. Further grounds of claim: Appropriate benefits as provided in the Act for the above grounds and other relief as the Workers' Compensation Commission may direct as just and proper. 12a. 12b. I am filing a claim. I am not requesting a hearing at this time. I am requesting a hearing. A $25 fee is required. Signature of Claimant/Representative Date Refer to R.67-205, R.67-206, R.67-207, and R.67-601 through R.67-615. Questions about the use of this form may be directed to the Commission's Judicial Department. WCC Form # 52 Revised 9/90 52 Employee's Notice of Claim and/or Request for Hearing, Death Case American LegalNet, Inc. www.FormsWorkFlow.com
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