South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5723 Claimant's Name: Address: City: Home Phone: Preparer's Name: State: Work Phone: Law Firm: Zip: Employer's Name: Address: City: Insurance Carrier: WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: State: Zip: Preparer's Phone #: Date of injury: _________________ (m/d/yyy) 1. Temporary Compensation Paid: Number of Weeks From To $ $ $ $ $ 2. The claimant returned to work on _____________ (m/d/yyyy) Amount With restrictions but at a salary not less than before the injury. Without restrictions. 3. The claimant agrees he or she was able to return to work on _____________. (m/d/yyyy) I agree that I was disabled for the period(s) indicated and I was paid compensation as shown above. I UNDERSTAND THAT MY WEEKLY TEMPORARY COMPENSATION CHECKS WILL STOP; HOWEVER, I GIVE UP NO RIGHTS TO COMPENSATION FOR FUTURE DISABILITY, FOR PERMANENT DISABILITY, DISFIGUREMENT OR MEDICAL CARE. The effect of this form has been fully explained to me, and I have received a copy of it. I understand that I should not sign this form until 15 days after I have returned to work or agree I was able to return to work. Claimant's Signature Employer's Representative Signature (Check one) Witness Claimant's Attorney Date Agreement Signed File this form with the Claims Department no later than 31 days from the date the claimant returned to work to terminate temporary compensation after the first 150 days after employer's notice of the injury according to R.67-505. Within the 150 period, obtain Form 17 to document that claimant agrees he or she is able to return to work. WCC Form # 17 Rev. Date 1/2014 17 RECEIPT OF COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com