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 WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: Address: City: Home Phone: Preparer's Name: The date of injury reported on Form 12A is: State: Work Phone: SSN: Employer's Name: Address: Zip: City: Insurance Carrier: State: Zip: Law Firm: __________ (m/d/yyyy) Preparer's Phone #: Check appropriate section(s). The Employer's Representative requests a hearing to: I. Stop payment of compensation. Claimant has reached maximum medical improvement and Claimant continues to receive temporary compensation payments. The employer's representative requests a hearing pursuant to § 42-9-260(D) to stop payment of temporary compensation. A hearing requested pursuant to this section must be held within sixty days of the date of the request. Claimant reached maximum medical improvement on (m/d/yyyy) (copy of medical report must be attached). Compensation payments are current as of ________ (m/d/yyyy) and shall continue until otherwise ordered or until Form 17 is signed by the claimant. A Form 17 was offered and refused on (m/d/yyyy). II. Address suspension, termination, or reduction of temporary disability payments for any cause. a. At any time pursuant to § 42-9-260(E). b. After the one-hundred-fifty day period has expired pursuant to § 42-9-260(F), R.67-505 and R.67-506. The basis for the termination/ suspension is III. Determine if compensation is due pursuant to § 42-9-10, § 42-9-20 or § 42-9-30 and, if so, in what amount, based on the following grounds: Claimant reached maximum medical improvement on IV. V. (m/d/yyyy) (copy of medical report must be attached). Request Credit for Overpayment of temporary compensation pursuant to § 42-9-210. Determine amount of compensation for claims involving a fatality. a. b. Payment of unpaid balance of compensation when employee dies pursuant to § 42-9-280. Amount of compensation for death of employee due to accident pursuant to § 42-9-290. VI. Mediation a. b. c. d. Mediation Mediation Mediation Mediation is requested to be ordered pursuant to Reg. 67-1801 B. is required pursuant to Reg. 67-1802. is requested by consent of the Parties pursuant to Reg. 67-1803. has been conducted by a duly qualified mediator and resulted in an impasse. Failure to respond pursuant to Reg. 67-208 B in writing or by submission of a Form 22 may result in ordered mediation pursuant to Reg. 67-1801 B. 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___, by first class postage certified mail personal service electronic service. A $25.00 filing fee and updated Form 18 is required. _________________________________________ Preparer's Signature ______________________________ Title ____ Email __________________ Date Questions about the use of this form should be directed to the Judicial Department at 803-737-5675, or judicial@wcc.sc.gov or mediation@wcc.sc.gov Refer to Regulations 67-211, 67-504, 67-505, 67-506; and 67-510. WCC Form # 21 Revised 7/15 21 Employer's Request for Hearing American LegalNet, Inc. www.FormsWorkFlow.com