South Carolina > Workers Comp
Request For Commission Review 30 - South Carolina
| Request For Commission Review Form. This is a South Carolina form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 803-737-5675 WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: Address: City: Home Phone: Preparer's Name: ( ) State: Work Phone: SSN: - - Employer's Name: Address: Zip: ( ) - City: Insurance Carrier: Preparer's Phone #: State: Zip: Law Firm: ( ) - REQUEST FOR COMMISSION REVIEW Request for Commission Review by claimant employer (check one) Date of injury: (m/d/yyyy) The undersigned makes application for review of the findings of the Commissioner in the above-captioned case. The request for review is based on the following grounds: (State the grounds of your appeal in the form of questions presented. Each question presented must contain a concise statement of one proposition of law or fact. Refer to evidence by title and exhibit number. Use additional pages if necessary). (Check one) Oral argument is is not requested. Appellant's request for oral argument is waived if not indicated on this form. I certify that I have served this document pursuant to R.67-211 by delivering a copy to Name Address on the day of , by first class mail personal service certified mail. Preparer's Signature Title Date Check this box if you are not represented by an attorney. If the claimant appeals and is representing himself or herself, the Judicial Department will prepare the additional copies of this form and serve this form on the opposing party. R.67-701B. Otherwise, file the original and four copies of this form with the Judicial Department. The appeal must be postmarked no later than 14 days from the date of service of the Hearing Commissioner's decision. R.67-701 and R.67-205. Attach the filing fee to this form. Attach a Form 32 if you are unable to pay the filing fee. Refer to R.67-701 through R.67-711 for additional information. WCC Form # 30 Rev. 3/97 30 REQUEST FOR COMMISSION REVIEW American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
