Periodic Report {18} | Pdf Fpdf Doc Docx | South Carolina

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Periodic Report {18} | Pdf Fpdf Doc Docx | South Carolina

Periodic Report {18}

This is a South Carolina form that can be used for Workers Comp.

Alternate TextLast updated: 4/13/2015

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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: Law Firm: Zip: Employer's Name: Address: City: Insurance Carrier: WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: State: Zip: 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 and R.67-804 for further information. Rev. Date 01/2014 WCC Form # 18 18 Periodic Report American LegalNet, Inc. www.FormsWorkFlow.com

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