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 #: Compensation Paid: 1. 2. 3. 4. 5. Number of Weeks T.T. Number of Weeks T.P. Number of Weeks P.P. Disfigurement Agreement and Final Release Number of Weeks From (m/d/yyyy) To (m/d/yyyy) Amount $ $ $ $ $ Total Compensation Paid 6. 7. Total Medical Benefits* Paid Funeral Benefits $ $ $ Case Denied Date of Injury: (m/d/yyyy) By signing this receipt, I acknowledge that I have received the compensation shown above. By: Claimant By: Employer's Representative Date (m/d/yyyy) Print or type the name of the person, other than the claimant, receiving benefits and sign below. By: Report of Additional Fees and Recoupment A. B. C. Carrier Reimbursement by Third Party Attorney's Fee Paid by Employer Attorney's Fee Paid by Claimant (Non-contingent fees only) $ $ $ File this form with the Claims Department according to R.67-414 and R.67-1204. A person, other than the claimant, receiving benefits should sign on the line provided. * Do not include as medical costs fees paid for expert testimony, fees for determining carrier's liability, costs of autopsy, birth and death certificates and impartial examination. Form 19 must be filed within 16 days of final payment of compensation. Form 19 must be filed when a claim is denied. WCC Form # 19 Rev. Date 01/2014 19 STATUS REPORT AND COMPENSATION RECEIPT American LegalNet, Inc. www.FormsWorkFlow.com