GREENVILLE, SC -Good form practice is one of the easiest ways to keep a workers’ compensation claim on track. When a form is filed late, not filed at all, contains missing information, or the wrong form is used, the result can be unnecessary costs, fines, and delays. For adjusters and employers, the goal is pretty simple: know which forms matter, know when they are due, and make sure the information in the forms matches what is actually happening in the claim.
Here is a practical look at some of the forms you are most likely to encounter in day-to-day South Carolina workers’ compensation claims.
- Core Reporting Forms
a. Form 12A – First Report of Injury
The Form 12A is where the reporting process starts. The employer must document every reported workplace injury and retain it for two years.
On the claims where medical expenses reach at least $2,500 or claims involving compensable lost time or permanency, the carrier (or self-insured employer) must file the Form 12A with the Commission within 10 business days.
For claims which do not initially meet the filing threshold, the Form 12A can generally be held until the threshold is reached. If that happens, the claim should be reported and marked as “Previously processed as medical only.” Filing a Form 12A does not mean the employer or carrier has admitted liability.
b. Form 12M – Annual Minor Medical Report
The Form 12M is filed once a year to report the medical-only claims that did not meet the reporting threshold during the previous calendar year. It is generally due by April 1 for the prior calendar year.
c. Form 20 – Statement of Earnings of Injured Employee
The Form 20 is used to establish the employee’s average weekly wage and compensation rate. As a practical matter, it is a good idea to complete and exchange the Form 20 with the opposing party early – ideally within 30 days of receiving notice of the claim or upon receipt of a Form 50.
d. Form 18 – Periodic Report
The Form 18 is a periodic report that is generally filed every six months following the date of injury until the claim is closed. These filings are easy to overlook, particularly on older or inactive claims. Missing one can result in a routine $200 fine.
- Temporary Benefits Forms
a. Form 15 – Temporary Compensation Report
The Form 15 is used when temporary compensation is being paid or when those benefits are being suspended or terminated. The form has three sections, each serving a different purpose:
i. Section I: Generally filed within 10 days after the first temporary total or temporary partial compensation payment.
ii. Section II: Used to suspend or terminate benefits during the first 150 days following notice of the injury. Supporting documentation must accompany the filing, and the form must be properly served on the employee.
iii. Section III: Allows the employee to request a hearing when he or she disputes the suspension or termination of temporary disability benefits.
b. Form 15S – Supplemental Report of Varying Temporary Partial Payments
Form 15S is required when temporary partial benefits fluctuate week to week. It should be filed with the next Form 18 or when temporary partial benefits end.
c. Form 17 – Receipt of Compensation
The Form 17 is generally used after the initial 150-day period following notice of injury when an employee has returned to work for at least 15 days or the employee agrees that he or she is able to work. The form must be signed by the employee. The Form 17 must be filed with the Commission no later than 31 days from the date the employee returned to work.
- Claim Initiation and Litigation Forms
a. Form 50 – Employee’s Notice of Claim and/or Request for Hearing
The Form 50 is the employee’s principal form for initiating a claim with the Commission. An employee can file a Form 50 simply to place the claim on record without requesting a hearing. If a hearing is requested, however, a $50 filing fee applies. Failure by the employee to timely file the initial Form 50 may result in an affirmative defense for the employer/carrier.
b. Form 51 – Employer’s Answer to Request for Hearing
The Form 51 is filed by the employer or carrier in response to the employee’s Form 50 Request for Hearing. It is due within 30 days of service of the Form 50. Failure to timely file a Form 51 results in waiver of affirmative defenses, including lack of notice, statute of limitations, willful intent, and intoxication. Form 51 is not required to be filed if the employee files a Form 50 Notice of Claim only.
c. Form 21 – Employer’s Request for Hearing
The Form 21 is used by the employer or carrier to request a hearing, including when seeking termination of temporary benefits after the 150-day period or when seeking determination of permanency. A $50 filing fee applies, and the required certificate of service should be included.
d. Forms 52 and 53
Forms 52 and 53 are used in death claims and generally serve as the counterparts to Forms 50 and 51.
- Settlement and Closure Forms
a. Form 16A – Agreement for Permanent Disability/Disfigurement Compensation
Form 16A is used to record a settlement that is NOT a clincher settlement. If the employee is unrepresented, Form 16A must be accompanied by the Form 14B and approved by the Commission through an informal conference. If the employee is represented, no approval by the Commission or informal conference is required; however, the form must be signed by the employee and his or her attorney. If an agreement is reached on a Form 16A, the employee has a right to file for a change of condition if his condition worsens within one year from the date of the last payment.
b. Form 19 – Status Report and Compensation Receipt
Form 19 must be filed to close a file with the Commission, either when the claim is denied or after all the benefits have been paid on the claim. When filing a Form 19 denying the claim, it must be accompanied by a copy of the letter notifying the employee or employee’s attorney of the denial. When filing a Form 19 on a settled claim, it must list all compensation and settlement amounts paid on the claim, and the dates of the temporary benefits must match the dates on previously filed Form 15 and/or Form 17. Form 19 on a settled claim must be signed by the employee.