Temporary Compensation Report South Carolina Workers' Compensation Commission

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WCC File #:

South Carolina Workers’ Compensation Commission

Carrier File #:

1333 Main Street, Suite 500

P.O. BOX 1715

Carrier Code #:

Columbia, SC 29202-1715

(803) 737-5723

Employer FEIN #:

Employer's Name:

Claimant's Name:

SSN:

Address:

City:

State:

Zip:

City:

State:

Zip:

Home Phone:

Work Phone:

Insurance Carrier:

Preparer’s Name:

Law Firm:

Preparer’s Phone #:

Date of injury: ____________

Date of Notice to Employer of Injury: ___________

(m/d/yyyy)

Payment of Temporary Compensation

Check one:

Initial period

Additional period

Corrected compensation rate

(choose A, B, or C)

A. Temporary Total at the compensation rate of

_______ per week. For this period of disability, disability began on

_______

(m/d /yyyy)

and the date of first payment was

_______

(m/d/yyyy)

B. Temporary Partial at the compensation rate of

____

per week. Note: When the Temporary Partial compensation rate will vary, report the first

payment here. Supplement this report throughout the period of Temporary Partial compensation by filing a Form 15S with the Form 18, which

shall be filed six months after the date of injury and each six months thereafter until the file is closed.

For this period of disability, disability began on

, and the date of first payment was

(m/d/yyyy)

Calculation of Temporary Partial Rate:

Average weekly wage before injury

Current weekly wage________________

Difference in wages before injury and now

$0.00

.6667_____________________________

Temporary Partial Compensation Rate

$0.00

C. Salary in lieu of Temporary

Total

Partial

compensation in the amount of

per week. For this period of disability,

(choose one)

disability began on

and the date of first payment of salary in lieu of temporary compensation was

(m/d/yyyy)

THIS SECTION MAY BE USED ONLY WITHIN 150 DAYS AFTER NOTICE TO EMPLOYER OF INJURY. ATTACH DOCUMENTATION AS TO THE REASON OF THE

TERMINATION.

II. Termination of Temporary Compensation

Temporary compensation payments were stopped on

for the following reason:

(m/d/yyyy)

Claimant has returned to work at least 15 days and no temporary partial compensation is due.

Claimant agrees he/she is able to return to work and has signed a Form 17.

Based on a good faith investigation, the claim is denied. Reason for denial:

Claimant has been released to return to work without restrictions and employment has been offered.

Claimant has been released to work at limited duty and employer has provided limited duty work consistent with the terms upon which the Employee

has been released.

Claimant has refused medical treatment, examination, or evaluation. Note: Benefits must be resumed if claimant accepts the treatment, examination, or

evaluation. Additional report must be filed if compensation is resumed.

I certify that this form has been served on the claimant per R.67-211.

Signature of Claims Administrator

Date

(m/d/yyyy)

III. Notice to Injured Worker or Legal Representative when Temporary Compensation Has Been Stopped:

The employer’s representative may stop temporary compensation within 150 days of the date of notice of injury for the above reasons. However, if you

believe that the temporary compensation should not have been stopped, you may request a hearing by signing below and returning this form to SCWCC

Judicial Department at the address at the top of this form. A hearing will be held within 60 days of receipt of your request to determine if temporary

compensation has been properly terminated.

MY SIGNATURE BELOW INDICATES THAT I DO NOT AGREE WITH THE TERMINATION OF TEMPORARY COMPENSATION.

I REQUEST A HEARING TO DETERMINE WHETHER I AM ENTITLED TO FURTHER TEMPORARY COMPENSATION PAYMENTS.

Check one: Form 15(II)

Has

Has not been received.

Signature of Claimant or Legal Representative

Date

(m/d/yyyy)

Employer’s representative must complete and file Form 15 with Claims Department within ten days after compensation begins or is terminated. Employer’s representative must serve

the Form 15 on the claimant when compensation begins per R.67-211. Employer’s representative must prepare and serve Form 20 within thirty days of beginning compensation per

R.67-1603. Employer’s representative must serve per R.67-211 two copies of the Form 15 on claimant immediately on termination of compensation with documentation attached as to

the reason for the termination. Injured worker may contest termination of compensation by completing section III of the Form 15 and filing it with Judicial Department.

WCC Form # 15

TEMPORARY COMPENSATION REPORT

Rev. 10/04