Wcc Form # 15s - South Carolina Workers' Compensation Commission
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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) 737-5723
Employer FEIN #:
Employer's Name:
Claimant's Name:
SSN:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
Home Phone:
Work Phone:
Insurance Carrier:
Preparer’s Name:
Law Firm:
Preparer’s Phone #:
Date of injury:
__________
(m/d/yyyy)
Supplemental Report of Varying Temporary Partial Payments
From
_______ through
_______, Claimant was paid $
_______ per week as temporary partial compensation. The weekly wage before the injury
was $
_______. The weekly wage for this period was $
_______.
From
_______ through
_______, Claimant was paid $
_______ per week as temporary partial compensation. The weekly wage before the injury
was $
_______. The weekly wage for this period was $
_______.
From
_______ through
_______, Claimant was paid $
_______ per week as temporary partial compensation. The weekly wage before the injury
was $
_______. The weekly wage for this period was $
_______.
From
_______ through
_______, Claimant was paid $
_______ per week as temporary partial compensation. The weekly wage before the injury
was $
_______. The weekly wage for this period was $
_______.
From
_______ through
_______, Claimant was paid $
_______ per week as temporary partial compensation. The weekly wage before the injury
was $
_______. The weekly wage for this period was $
_______.
From
_______ through
_______, Claimant was paid $
_______ per week as temporary partial compensation. The weekly wage before the injury
was $
_______. The weekly wage for this period was $
_______.
From
_______ through
_______, Claimant was paid $
_______ per week as temporary partial compensation. The weekly wage before the injury
was $
_______. The weekly wage for this period was $
_______.
From
_______ through
_______, Claimant was paid $
_______ per week as temporary partial compensation. The weekly wage before the injury
was $
_______. The weekly wage for this period was $
_______.
From
_______ through
_______, Claimant was paid $
_______ per week as temporary partial compensation. The weekly wage before the injury
was $
_______. The weekly wage for this period was $
_______.
In an ongoing period of temporary partial, when the compensation rate varies from week to week, the employer’s representative shall report the first payment on a
Form 15 according to R.67-503. Supplemental payments shall be reported on a Form 15S, to be filed with the document stopping that period of temporary partial
compensation or 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. R.67-503.
15S
WCC Form # 15S
Supplemental Report of Varying
Rev. 3/97
Temporary Partial Payments
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