Annual Minor Medical Report
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Annual Minor Medical Report Form. This is a South Carolina form and can be use in Workers Comp.
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Tags: Annual Minor Medical Report, 12M, South Carolina Workers Comp,
South Carolina Workers’ Compensation Commission
1333 Main Street, Suite 500
P.O. BOX 1715
Columbia, SC 29202-1715
(803) 737-5722
Minor Medical Claims for
Calendar Year _
__
(For Commission Use Only:
ATTACH MAILING LABEL IDENTIFYING
INSURANCE CARRIER IN THIS AREA)
I.
Carrier Identification
If missing or incorrect above
Insurance Carrier FEIN:
Insurance Carrier SCWCC Code No.:
Insurance Carrier Name:
II.
Reporting Contact Address
The address shown above is the correct contact for completion of this form.
OR
Future editions of this form should be sent to the following address:
Address:
City:
III.
State:
Zip:
Statistical Report includes ALL minor medical claims paid in the name of or under the authority of the named Carrier/Selfinsurer during the calendar year.
Submitted by:
Telephone:
Preparer’s Name
Total # minor medical claims filed during calendar year:
Total medical costs paid during calendar year:
$
File this form with the Accident Reporting Division on or before April 1 following the reporting year. Only one report per carrier will be accepted.
WCC Form # 12M
Rev. 5/06
12M
ANNUAL MINOR MEDICAL REPORT
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