South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5675 www.wcc.sc.gov WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: Address: City: Home Phone: Preparer's Name: Check applicable claims and complete all blanks. 1. State: Work Phone: SSN: Employer's Name: Address: Zip: City: Carrier: Preparer's Phone #: State: Zip: The employee sustained a compensable accidental injury to the on _______________ (m/d/yyyy) in _____________________________(county), State of _______________ (state). (part of the body) 2. 3. 4. That the Second Injury Fund was put on notice of the claim on That the carrier concluded the disability claim by Award _____________ (m/d/yyy). Agreement on _____________ (m/d/yyyy) . That the subsequent injury combined with or was aggravated by the below-named permanent impairment under S.C. Code Section 42-9-400(d): a. Listed Impairment ­ (1) ­ (33) b. (34) (a) c. (34) (b) 5. a. That the impairment preexisted; b. That the impairment was permanent; and c. That the impairment is a physical condition. 6. 7. 8. 9. That the prior impairment combined with or was aggravated by the subsequent injury. That the combination/aggravation substantially increased the liability of the carrier for: That the impairment was a hindrance or obstacle to employment or re-employment. a. That the employer has knowledge of the prior impairment; b. That the impairment was unknown to the employee and the employer; or c. That the employee concealed the prior impairment from the employer. disability medical or both. 10. 11. That the subsequent injury would not have occurred "but for" the prior impairment. That the above claim qualifies for reimbursement under S.C. Code Section 42-9-410 because: 12. Other grounds for claim: Mediation a. b. c. d. Mediation Mediation Mediation Mediation is requested to be ordered pursuant to Reg. 67-1801 B. is required pursuant to Reg. 67-1802. is requested by consent of the Parties pursuant to Reg. 67-1803. has been conducted by a duly qualified mediator and resulted in an impasse. Questions regarding mediation may be submitted to mediation@wcc.sc.gov. I certify I have served this document pursuant to Reg. 67-211 by delivering a copy to_______________________________________ address__________________________________________________________ on the _________day of _______________20_____, by first class postage certified mail personal service. A $25.00 filing fee and updated Form 18 is required. _________________________________________ Preparer's Signature ______________________________ Title ____ __________________ Date Email Questions regarding this form should be directed to the Judicial Department at 803.737.5675, or judicial@wcc.sc.gov or mediation@wcc.sc.gov. Refer to Regulations 67-204 through 67-211 and Regulations 601 through 67-615 as well as Reg. 67-1801. WCC Form # 54 Revised 7/13 54 Employer's Notice of Claim and/or Request for Hearing American LegalNet, Inc. www.FormsWorkFlow.com