The Wcc Form 58 is a form used to request records from the government. The form can be used to request information from any level of government, from local municipalities to the federal government. The form can be used to request information on a variety of topics, including public meetings, contract bids, and Freedom of Information Act requests. Anyone can use the Wcc Form 58 to request records from the government, and there is no cost associated with using the form. accessing public records. The Wcc Form 58 is an easy-to-use form that can be used to request records from any level of government.
This figure holds specifics of wcc form 58. It is suggested that you check out this info before you decide to begin editing the file.
| Question | Answer |
|---|---|
| Form Name | Wcc Form 58 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | amending, wcc, Repetitive, South_Carolina |
South Carolina Workers’ Compensation Commission
1333 Main Street, Suite 500
P.O. BOX 1715
Columbia, SC
(803)
WCC File No:____________
Claimant's Name: |
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Employer's Name: |
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Home Phone: |
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Work Phone: |
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Carrier: |
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Preparer's Name: |
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Preparer’s Phone #: |
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A claim for workers’ compensation benefits is made based on the following grounds: |
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Injury |
Illness |
Repetitive Trauma |
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1. |
Compensation Rate: |
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2. AWW: $ |
Date of Injury: |
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3.Type of injury and body part(s):
4.Facts in controversy:
5.Legal issues involved:
6.Unusual aspects:
7.Witnesses (designate if expert):*
8.Exhibits:
9.Medical evidence (indicate report pursuant to
10.Name, address, and specialty, if any, of the treating physician:
11.Impairment rating(s); body part(s); physician and date of opinion:
12.I am amending my Form 50/51 in the following manner: ____________________________________________________________
I verify the contents of this form are accurate and true to the best of my knowledge.
Signature:
Date of hearing:
On behalf of Claimant
Email:
Time needed for hearing:
Employer
File this form and proof of service on the opposing party according to
WCC Form # 58 |
58 |
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Rev. 9/07 |
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