I.C. File #: South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5675 The use of this form is required under the provisions of the South Carolina Workers' Compensation Law. ENTITLEMENT TO RIGHT OF ACTION In the Workers' Compensation Claim of , Employee , Claimant(s) vs. , Employer , Carrier The undersigned carrier or self-insurer employer assumes and asserts herewith entitlement to bring a third party action in the above matter against , as defendant(s) on the ground that the right of action of the injured employee or his surviving Workers' Compensation beneficiary or (other person entitled to sue) to sue the third party has passed to the carrier or self-insurer by statutory assignment for (check one): Failure to effect a settlement or to commence an action against the third party within one (1) year after the acceptance of liability for payment of Workers' Compensation by the carrier or self-insurer employer; Failure to commence an action against the third party and there remains thirty (30) days or less before time for bringing such action expires; AND That the above-named injured employee, claimant(s) and were served written notice by certified mail on , (other person entitled to sue) , , that failure to commence an an appropriate action against the third party will operate as an assignment of the cause of action to the Workers' Compensation carrier or self-insurer employer; and that twenty (20) days have passed since that notice of , . Workers' Compensation Carrier or Self-Insurer Employer DATED: Attorney for Carrier or Self-Insurer Employer WCC Form # S-3 Rev. 1986 S-3 Entitlement to Right of Action American LegalNet, Inc. www.FormsWorkFlow.com