Wcc Form 12M PDF Details

The WCC 12M form is a critical document for insurance carriers operating under the South Carolina Workers’ Compensation Commission. Located at 1333 Main Street, Suite 500, P.O. BOX 1715, Columbia, SC 29202-1715, this form serves as an annual submission tool for minor medical claims processed over the calendar year. It requires detailed information including the insurance carrier's FEIN, SCWCC Code No., and official name, ensuring that all submissions are accurately attributed and processed. Furthermore, it mandates that carriers specify a reporting contact address to facilitate future communications. This form, which is integral to the Commission's operations, encapsulates all minor medical claims paid by or on behalf of the carrier, emphasizing the total number of claims filed and the total medical costs paid throughout the year. Its submission, due no later than April 1 following the reporting year, allows for a streamlined audit of minor medical claims, underscoring its importance in maintaining transparency and efficiency in workers' compensation claims management. As such, the WCC 12M form plays a pivotal role in the oversight of minor medical claims, ensuring that both the carriers and the Commission have a comprehensive record of such transactions for each calendar year.

QuestionAnswer
Form NameWcc Form 12M
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesjollibee application form, Statistical, WCC, editions

Form Preview Example

South Carolina Workers’ Compensation Commission

1333 Main Street, Suite 500

P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5722

(For Commission Use Only:

ATTACH MAILING LABEL IDENTIFYING INSURANCE CARRIER IN THIS AREA)

Minor Medical Claims for

Calendar Year _

__

I.Carrier Identification

If missing or incorrect above

Insurance Carrier FEIN:

 

Insurance Carrier SCWCC Code No.:

Insurance Carrier Name:

II.Reporting Contact Address

The address shown above is the correct contact for completion of this form.

OR

Future editions of this form should be sent to the following address: Address:

City:State: Zip:

III.Statistical Report includes ALL minor medical claims paid in the name of or under the authority of the named Carrier/Self- insurer during the calendar year.

Submitted by:

 

 

 

Telephone:

 

 

 

Preparer’s Name

 

 

 

 

 

 

 

Total # minor medical claims filed during calendar year:

 

 

 

 

 

 

 

Total medical costs paid during calendar year:

$

 

 

 

 

 

File this form with the Accident Reporting Division on or before April 1 following the reporting year. Only one report per carrier will be accepted.

WCC Form # 12M

12M

ANNUAL MINOR MEDICAL REPORT

Rev. 5/06

 

 

 

How to Edit Wcc Form 12M Online for Free

II can be filled out online in no time. Just use FormsPal PDF tool to perform the job fast. Our team is dedicated to providing you the best possible experience with our editor by regularly adding new features and upgrades. Our editor is now a lot more user-friendly thanks to the most recent updates! So now, filling out PDF files is easier and faster than ever. All it requires is a couple of simple steps:

Step 1: Open the PDF form in our tool by clicking the "Get Form Button" at the top of this webpage.

Step 2: This tool provides the capability to customize PDF documents in a variety of ways. Transform it by writing customized text, adjust what is already in the file, and put in a signature - all readily available!

In order to complete this PDF document, make sure you provide the information you need in each field:

1. First, once filling in the II, start in the part that contains the following fields:

How one can prepare WCC portion 1

2. Once your current task is complete, take the next step – fill out all of these fields - The address shown above is the, Future editions of this form, Address, City, State, Zip, III, Statistical Report includes ALL, Submitted by, Preparers Name, Telephone, Total minor medical claims filed, Total medical costs paid during, and File this form with the Accident with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Total minor medical claims filed, Telephone, and The address shown above is the of WCC

Be really mindful when filling out Total minor medical claims filed and Telephone, as this is where a lot of people make mistakes.

Step 3: You should make sure the details are accurate and click on "Done" to complete the project. Get hold of the II as soon as you subscribe to a free trial. Instantly get access to the pdf form in your personal account, along with any modifications and changes automatically preserved! FormsPal is committed to the personal privacy of all our users; we make sure that all information entered into our tool is confidential.

Wcc Form 12M isn’t the one you’re looking for?

Related Documents