Application For Lump Sum Award {24}

South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 803-737-5723 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: ( ) - Application for Lump Sum Award The claimant named above has been granted an award of compensation and the award has been paid in periodic payments for not less than six weeks. The claimant requests a lump sum payment of the award, reduced to present day value, according to the Regulations of the Commission. (Check One) The employer and its representative consent to the payment of the award in lump sum as shown by the letter attached to this application. The employer and its representative object to the payment of the award in lump sum as shown by the letter attached to this application. In this space, please state the reason(s) for requesting lump sum payment and intended use of the money. Claimant / Representative Date (m/d/yyyy) Do not write in this space. Approved: Set for hearing: Commissioner _____________________________________________ File this form with the Claims Department. Refer to R.67-1605 and R.67-1606 for additional information. If the claimant is not represented, the Claims Department will contact the employer's representative to inquire if it consents to a lump sum payment. If either the employer's representative or the Commissioner do not agree to payment in lump sum, a hearing will be set automatically and the parties notified. WCC Form # 24 Rev. 9/90 24 Application for Lump Sum Award American LegalNet, Inc. www.FormsWorkFlow.com