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S.C. Workers’ Compensation Commission – First Report of Injury or Illness

1 EMPLOYEE/WAGE
2 OCCURRENCE/TREATMENT
3 OTHER
  • This is the code which represents the nature of the employer’s business, which is contained in the Standard Industrial Classification Manual or the North American Industry Classification System, published by the Federal Office of Management and Budget.
  • The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant.
  • Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim.
  • Enter the name of your insurance agent if known. This information can be found on your insurance policy.
  • Enter your insurance agent code number if known. This information can be found on your insurance policy.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • This is the primary occupation of the claimant at the time of the accident or exposure.