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: State: Work Phone: SSN: Employer's Name: Address: Zip: City: Insurance Carrier: State: Zip: Law Firm: Preparer's Phone #: Request for Commission Review by REQUEST FOR COMMISSION REVIEW Claimant Employer (check one) Date of Injury or Illness: ____________ (m/d/yyyy) The undersigned makes application for review of the findings of the Commissioner in the above-captioned case. The request for review is based on the following grounds: (State the grounds of your appeal in the form of questions presented. Each question presented must contain a concise statement of one proposition of law or fact. Refer to evidence by title and exhibit number. Use additional pages if necessary). (Check one) Oral argument Mediation is is not requested. Appellant's request for oral argument is waived if not indicated on this form. Mediation is requested by consent of the Parties pursuant to Reg. 67-1803. 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. _________________________________________ Preparer's Signature ______________________________ Title Email ____ _____________________ Date Check this box if you are not represented by an attorney Questions about the use of this form should be directed to the Judicial Department at 803.737.5675 or appeals@wcc.sc.gov. If the claimant appeals and is not represented by counsel, the Judicial Department will properly serve this form pursuant to Reg. 67-607 C. Pursuant to Reg. 67-205 and Reg. 701, the appeal must be postmarked no later than 14 days from the date of service of the Decision and Order of the Hearing Commissioner along with the filing fee. Attach a Form 32, if you are unable to pay the filing fee. Refer to Reg. 67-211 and Reg. 67-701 through 711. WCC Form # 30 Revised 7/13 30 REQUEST FOR COMMISSION REVIEW American LegalNet, Inc. www.FormsWorkFlow.com