Get the free WCC Form # 21 Employer's Request for Hearing - Workers ... - wcc sc

WCC File #: South Carolina Workers Compensation Commission 1333 Main Street, Suite 500 Post Office Box 1715 Columbia, South Carolina 29202-1715 (803) 737.5675 www.wcc.sc.gov Claimant's Name: Carrier

How to fill out wcc form 21 employer39s

How to fill out WCC Form 21 Employer's:

1. Begin by entering the employer's name, address, and contact information in the designated fields on the form.
2. Provide the date of the accident or injury in the appropriate section.
3. Specify the state and county where the accident occurred.
4. Enter the injured worker's name, address, and contact information.
5. Indicate the worker's Social Security number and date of birth.
6. Provide a detailed description of the accident or injury, including the date, time, location, and a brief explanation of what happened.
7. Specify the body parts affected by the injury and the nature of the injury.
8. If medical attention was required, include the name and contact information of the treating physician or facility.
9. Describe any medical treatment or surgeries the injured worker has received or is currently undergoing.
10. Include any supporting documents or records related to the injury, such as medical reports or witness statements.
11. Sign and date the form to certify its accuracy and completeness.

Who needs WCC Form 21 Employer's:

1. Employers who have experienced workplace accidents or injuries involving their employees.
2. Workers' Compensation Commissions or insurance providers who require documentation of the incident for processing claims and determining liability.
3. Injured workers or their representatives who need to report the accident or injury to their employer and seek compensation or medical benefits.

For pdfFiller’s FAQs

What is wcc form 21 employer39s?

WCC form 21 employer39s is a form used in workers' compensation cases to report information about the employer.

Who is required to file wcc form 21 employer39s?

Employers who have employees involved in workers' compensation cases are required to file WCC form 21.

How to fill out wcc form 21 employer39s?

WCC form 21 employer39s can be filled out by providing information about the employer, employee, and details of the workers' compensation case.

What is the purpose of wcc form 21 employer39s?

The purpose of WCC form 21 employer39s is to report relevant information about the workers' compensation case involving the employer.

What information must be reported on wcc form 21 employer39s?

Information such as employer details, employee details, and specifics of the workers' compensation case must be reported on WCC form 21.

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