South Carolina > Workers Comp
Periodic Report 18 - South Carolina
| Periodic Report Form. This is a South Carolina form and can be used in Workers Comp . |
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South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5723 Claimant's Name: Address: City: Home Phone: Preparer's Name: ( ) State: Work Phone: ( Zip: ) SSN: Employer's Name: Address: City: Insurance Carrier: WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: State: Zip: Law Firm: Preparer's Phone #: ( ) - 1. Date of injury: (m/d/yyyy) 2. Total Weeks Compensation Paid: 3. Type of Compensation Paid (TP or TT)/Periods of Payment: (m/d/yyyy) (m/d/yyyy) Type: Type: Type: 4. Date of First Payment: (m/d/yyyy) From: From: From: To: To: To: 5. Total Amount Paid (a) Compensation: (b) Medical (Include Nursing, Hospital, Drugs, Etc.): $ $ No (check one) 6. Informal Conference is Requested: Yes Use these lines to send a memo to the Commission: ( ) - Employer's Representative Phone Date Type or print all information. File this form six months after the alleged injury date and each six months until the Commission's File is closed. Form 18 must be filed whether or not compensation is ongoing. Check "yes" after Number 6 to request an informal conference. Refer to R.67413, R.67-507, and R.67-804 for further information. WCC Form # 18 Rev. Date 3/96 18 Periodic Report American LegalNet, Inc. www.FormsWorkFlow.com
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