WCC File #: South Carolina Workers’ Compensation Commission 1612 Marion St. P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5675 Claimant's Name: Carrier File #: Carrier Code #: Employer FEIN #: SSN: - - Employer's Name: Address: Address: City: State: Home Phone: ( ) - Work Phone: Zip: ( ) City: - State: Zip: Carrier: Preparer's Name: Preparer’s Phone #: ( ) - By signing this document, I do hereby certify that the issue involved in this motion for relief is such that immediate attention is necessary and that the issue is capable of speedy resolution by the jurisdictional Commissioner. My motion (attached) for expedited adjudication is made on the following grounds (R.67-215): Death benefits are due and the employer/ carrier’s investigation establishes that no dispute exists as to the disposition of death benefits (attach names, ages, and addresses of death beneficiaries) The parties have reached a settlement agreement on a Form 16, clincher or resolution and distribution of third party proceeds, involving unrepresented claimants, and seek an approval The case is accepted and involves medical treatment recommended by an authorized treating physician and employer/carrier disagrees or employer/carrier has failed to appoint an authorized physician The case involves a request for a medical evaluation on change of condition pursuant to Regulation 67-602(c) Employer’s representative has terminated payments of compensation and has not appropriately filed a Form 21, Form 15 or Form 17 The case is accepted and the employer/carrier has not paid or has stopped paying medical bills, mileage and medication expenses The issue is determination of a lump sum payment under §42-9-301 and Regulation 67-1605. This request is on behalf of the Claimant $25 Filing Fee is attached (MUST be attached to this request) Carrier _____________________________________________ Signature of Moving Party ______________________________________________ Date This form and motion must be served on all parties and filed with the Judicial Department. A proof of service and filing fee must be attached. WCC Form # 40 Rev. 10/04 40 Motion for Expedited Adjudication American LegalNet, Inc. www.USCourtForms.com