Wcc Form 58 PDF Details

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.

Form NameWcc Form 58
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesSouth_Carolina, scwcc forms, wcc, pursuant

Form Preview Example

South Carolina Workers’ Compensation Commission

1333 Main Street, Suite 500

P.O. BOX 1715

Columbia, SC 29202-1715

(803) 737-5675



WCC File No:____________

Claimant's Name:










Employer's Name:











































Home Phone:



Work Phone:
































Preparer's Name:










Preparer’s Phone #:












































































A claim for workers’ compensation benefits is made based on the following grounds:




Repetitive Trauma




Compensation Rate:


2. AWW:


Date of Injury:

3.Type of injury and body part(s): ________________________________________________________________________________________________

4.Facts in controversy:

5.Legal issues involved:

6.Unusual aspects:

7.Witnesses (designate if expert):*


9.Medical evidence (indicate report pursuant to R.67-612; deposition or appearance):

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:


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.

I certify I have served this document pursuant to Reg. 67-211 by delivering a copy to_______________________________________

address __________________________________________________________ on the _____ day of _______________20_____,


first class postage

certified mail

personal service

electronic service

I verify the contents of this form are accurate and true to the best of my knowledge.

















Date of hearing:



Time needed for hearing:





















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. 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. * Commissioners reserve the right to admit expert witnesses at hearings.

WCC Form # 58



Revised 7/15




How to Edit Wcc Form 58 Online for Free

It is easy to fill in the gov blanks. Our tool makes it virtually effortless to fill in any sort of form. Below are the basic four steps you'll want to consider:

Step 1: You should press the orange "Get Form Now" button at the top of this webpage.

Step 2: At the moment, you can begin editing your gov. Our multifunctional toolbar is available to you - insert, delete, transform, highlight, and undertake other commands with the content in the file.

For every single area, complete the information asked by the system.

wcc empty fields to complete

Complete the Exhibits, Medical evidence indicate report, Name address and specialty if any, Impairment ratings body parts, Mediation, I am amending my Form in the, a Mediation is requested to be, Questions regarding mediation may, I certify I have served this, personal service, certified mail, electronic service, I verify the contents of this form, Signature, and Email section with the information asked by the system.

Finishing wcc step 2

Provide the main data the Signature, Date of hearing, Email, Time needed for hearing, Questions about the use of this, WCC Form Revised, and PREHEARING BRIEF section.

Finishing wcc part 3

Step 3: When you click the Done button, your final document is conveniently transferable to every of your gadgets. Alternatively, you will be able to deliver it by means of email.

Step 4: You will need to make as many copies of your file as you can to stay away from possible misunderstandings.

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