Wcc Form 54 - Employer'S Notice Of Claim And/or Request For Hearing
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1WCC File #:
South Carolina Workers’ Compensation Commission
Carrier File #:
1333 Main Street, Suite 500
P.O. BOX 1715
Carrier Code #:
Columbia, SC 29202-1715
(803) 737-5675
Employer FEIN #:
Claimant's Name:
SSN:
Employer's Name:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
Home Phone:
Work Phone:
Carrier:
Preparer’s Phone #:
Preparer's Name:
Check applicable claims and complete all blanks.
1.
The employee sustained a compensable accidental injury to the
(part of the body)
on _______________ (m/d/yyyy) in _____________________________(county), State of _______________ (state).
2.
That the Second Injury Fund was put on notice of the claim on
_____________ (m/d/yyy).
3.
That the carrier concluded the disability claim by
Award
Agreement on _____________ (m/d/yyyy) .
4.
That the subsequent injury combined with or was aggravated by the below-named permanent impairment under S.C. Code Section 42-9-400(d):
a. Listed Impairment – (1) – (33)
b. (34) (a)
c. (34) (b)
5.
a. That the impairment preexisted;
b. That the impairment was permanent; and
c. That the impairment is a physical condition.
6.
That the prior impairment combined with or was aggravated by the subsequent injury.
7.
That the combination/aggravation substantially increased the liability of the carrier for:
disability
medical or
both.
8.
That the impairment was a hindrance or obstacle to employment or re-employment.
9.
a. That the employer has knowledge of the prior impairment;
b. That the impairment was unknown to the employee and the employer; or
c.
That the employee concealed the prior impairment from the employer.
10.
That the subsequent injury would not have occurred “but for” the prior impairment.
11.
That the above claim qualifies for reimbursement under S.C. Code Section 42-9-410 because:
Other grounds for claim:
12.
Mediation
a.
Mediation is requested to be ordered pursuant to Reg. 67-1801 B.
b.
Mediation is required pursuant to Reg. 67-1802.
c.
Mediation is requested by consent of the Parties pursuant to Reg. 67-1803.
d.
Mediation has been conducted by a duly qualified mediator and resulted in an impasse.
Questions regarding mediation may be submitted to mediation@wcc.sc.gov.
I certify I have served this document pursuant to Reg. 67-211 by delivering a copy to_______________________________________
address__________________________________________________________ on the _________day of _______________20_____,
by
first class postage
certified mail
personal service. A $25.00 filing fee and updated Form 18 is required.
_________________________________________
______________________________
____
__________________
Preparer’s Signature
Title
Email
Date
Questions regarding this form should be directed to the Judicial Department at 803.737.5675, or judicial@wcc.sc.gov or mediation@wcc.sc.gov. Refer to
Regulations 67-204 through 67-211 and Regulations 601 through 67-615 as well as Reg. 67-1801.
54
Employer’s Notice of Claim and/or
WCC Form # 54
Request for Hearing
Revised 7/13
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