Form 58 at a glance
What it is: Form 58 is the South Carolina Workers' Compensation Commission's Pre-Hearing Brief for a claim for workers' compensation benefits.
Who signs: "I verify the contents of this form are accurate and true to the best of my knowledge."
A filled-in Form 58 example: a claimant files the pre-hearing brief
How to fill out Form 58, box by box
Claimant's Name, Employer's Name and WCC File No
Enter the WCC File No.
Enter the Claimant's Name and the Employer's Name, each with its Address, City, State and Zip.
Phones, Carrier and Preparer
Enter the Home Phone and the Work Phone.
Enter the Carrier.
Enter the Preparer's Name and the Preparer's Phone #.
Grounds: Injury, Illness or Repetitive Trauma
The grounds for the claim are Injury, Illness or Repetitive Trauma.
Compensation Rate, AWW and Date of Injury
Enter the Compensation Rate, the AWW after the $ and the Date of Injury.
Type of injury, Facts in controversy, Legal issues involved and Unusual aspects
Enter the Type of injury and body part(s).
Enter the Facts in controversy.
Enter the Legal issues involved.
Enter the Unusual aspects.
Witnesses, Exhibits, Medical evidence, treating physician and Impairment
Enter the Witnesses (designate if expert).
Enter the Exhibits.
For Medical evidence, indicate report pursuant to R.67-612; deposition or appearance.
Enter the Name, address, and specialty, if any, of the treating physician.
Enter the Impairment rating(s); body part(s); physician and date of opinion.
Amending your Form 50/51
If you are amending your Form 50/51, the box I am amending my Form 50/51 in the following manner is where you enter how you are amending it.
Mediation
a. Mediation is requested to be ordered pursuant to Reg. 67-1801 B. b. Mediation is required pursuant to Reg. 67-1802. c. Mediation is requested by consent of the Parties pursuant to Reg. 67-1803. d. Mediation has been conducted by a duly qualified mediator and resulted in an impasse. Questions regarding mediation may be submitted to mediation@wcc.sc.gov.
SIGN: Signature, Email, Date of hearing and Time needed for hearing
"I certify I have served this document pursuant to Reg. 67-211. See attached certificate of service."
Sign on the Signature line; enter the Email, Date of hearing and Time needed for hearing.
More rules for Form 58
File this form and proof of service on the opposing party according to R.67-611 and R.67-212. Do not send medical reports. Questions about the use of this form should be directed to the Jurisdictional Commissioner. Refer to Regulations 67-204 through 67-211 and Regulations 67-601 through 67-615; as well as Regulation 67-1801.
Sources
[1] Form 58 (Revised 9/23), South Carolina Workers' Compensation Commission (the Official source link on this page).
