WCC File #: South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5675 Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: Address: City: Home Phone: Preparer's Name: ( ) State: Work Phone: SSN: - - Employer's Name: Address: Zip: ( ) - City: Insurance Carrier: Preparer's Phone #: ( ) State: Zip: Law Firm: - Occupational Disease Waiver The undersigned applicant does hereby waive my right to make a claim for compensation for the occupational disease indicated while employed by the above employer. I understand my right to waive liability for the above-named disease as provided for in Section 42-11-80 and Regulation 67-1002 of the South Carolina Workers' Compensation Law, which reads in part: "If an employee who had previously suffered from an occupational disease desires to continue in an employment to which such a disease is a hazard, he may waive his right to receive further benefits for disablement or disability from such disease by written agreement approved by the Commission in accordance with such rules as it may promulgate." Therefore, it is my understanding that I only waive my right to receive compensation for the above-named disease and still retain all other rights given an employee under the South Carolina Workers' Compensation Law. Applicant Name Applicant Signature/Date Employee's Legal Representative Name Signature of Claimant or Legal Representative/Date Witness Name Witness Signature/Date Approving Commissioner's Name Signature of Approving Commissioner/Date Employee's representative must complete and file Form 65 and physician's statement (per R.67-1002) with the Judicial Department. WCC Form # 65 Rev. 1/97 65 Occupational Disease Waiver American LegalNet, Inc. www.FormsWorkFlow.com