HOME
ABOUT
- THE TEAM
SERVICES
SHOWCASE
NEWS
CONTACT
CLOCK

RESOURCES

REQUEST A QUOTE

SC WORKERS COMP

1EMPLOYEE/WAGE

2OCCURRENCE/TREATMENT

3OTHER

This field is hidden when viewing the form
Employer Name
This field is hidden when viewing the form
Employer Address
Street Address City State ZIP Code
This field is hidden when viewing the form
Industry Code
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.
This field is hidden when viewing the form
Employer FEIN
This field is hidden when viewing the form
Carrier/Administration Claim Number
This field is hidden when viewing the form
OSHA Log Number
This field is hidden when viewing the form
Report Purpose Code
This field is hidden when viewing the form
Jurisdiction
This field is hidden when viewing the form
Jurisdiction Claim Number
This field is hidden when viewing the form
Insured Report Number
This field is hidden when viewing the form
Employer's Location Address (If different)
Street Address City State ZIP Code
This field is hidden when viewing the form
Location No.
This field is hidden when viewing the form
Phone No.
This field is hidden when viewing the form
Carrier Name
First Last
The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant.
This field is hidden when viewing the form
Carrier Address
Street Address Address Line 2 City State ZIP Code
This field is hidden when viewing the form
Carrier Phone No.
This field is hidden when viewing the form
Carrier FEIN
This field is hidden when viewing the form
Policy Period
From To
This field is hidden when viewing the form
Check if appropriate
- Self Insurance
This field is hidden when viewing the form
Policy/Self-Insured Number
This field is hidden when viewing the form
Claims Administrator Name
First Last
Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim.
This field is hidden when viewing the form
Claims Administrator Address
Street Address Address Line 2 City State ZIP Code
This field is hidden when viewing the form
Claims Administrator Phone No.
This field is hidden when viewing the form
Administrator FEIN
This field is hidden when viewing the form
Agent Name
First Last
Enter the name of your insurance agent if known. This information can be found on your insurance policy.
This field is hidden when viewing the form
Agent Code Number
Enter your insurance agent code number if known. This information can be found on your insurance policy.
Employee Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Phone No.
Date of Birth
MM slash DD slash YYYY
Sex
- Male
- Female
- Unknown
No. of Dependents
Social Security Number
Marital Status
- Unmarried / Single / Divorced
- Married
- Separated
- Unknown
Date Hired
MM slash DD slash YYYY
State of Hire
Occupation/Job Title
This is the primary occupation of the claimant at the time of the accident or exposure.
Employment Status
- Full-Time
- Part-Time
- Not Employed
- On Strike
- Disabled
- Retired
- Unknown
- Apprenticeship Full-Time
- Apprenticeship Part-Time
- Volunteer
- Seasonal
- Piece Worker
NCCI Class Code
Rate
Per
- Day
- Week
- Month
- Other
Days Worked/Week
Full pay for day of injury
- Yes
- No
Did Salary Continue?
- Yes
- No

Time Employee Began Work

: HH

MM

AM/PM
Date of Injury/Illness *
MM slash DD slash YYYY
Time of Occurence

: HH

MM

AM/PM
Cannot Be Determined
- Cannot Be Determined
Last Work Date
MM slash DD slash YYYY
Date Employer Notified
MM slash DD slash YYYY
Date Disability Began
MM slash DD slash YYYY

The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise designated by statute.
Contact Name
Enter the name of the individual at the employer’s premises to be contacted for additional information.
Contact Phone No.
Did injury/illness/exposure occur on employer's premises?
- Yes
- No
Type of Injury/Illness
Briefly describe the nature of the injury or illness, (e.g. Lacerations to the forearm)
Type of Injury/Illness Code
Part of Body Affected
Indicate the part of body affected by the injury/illness, (e.g. Right forearm, lower back).
Part of Body Affected Code
Department or location where accident or illness exposure occurred
(e.g. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)
If the accident or illness exposure did not occur on the employer’s premises, enter address or location. Be specific.
All equipment, materials, or chemicals employee was using when accident or illness exposure occurred
(e.g. Acetylene cutting torch, metal plate)
List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush, and paint.
Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee’s injury or illness.
Specific activity the employee was engaged in when the accident or illness exposure occurred
(e.g. Cutting metal plate for flooring)
Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting.
Work process the employee was engaged in when accident or illness exposure occurred
Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (e.g. walking along a hallway).
How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill
(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.)
Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker’s right wrist was broken in the fall.
Cause of Injury Code
Date return(ed) to work
MM slash DD slash YYYY

Enter the date following to most recent disability period on which the employee returned to work.
If fatal, give date of death
MM slash DD slash YYYY
Were safeguards or safety equipment provided?
- Yes
- No
Were they used?
- Yes
- No
Physician/Health Care Name
Physician/Health Care Address
Street Address Address Line 2 City State ZIP Code
Hospital or Off Site Treatment Name
Hospital or Off Site Treatment Address
Street Address Address Line 2 City State ZIP Code
Initial Treatment
- 0 - No medical treatment
- 1 - Minor: By Employer
- 2 - Minor Clinic/Hospital
- 3 - Emergency Care
- 4 - Hospitalized > 24 hours
- 5 - Future major medical / Lost time anticipated

WITNESSES (NAME & PHONE #)
Date Administrator notified
MM slash DD slash YYYY
Date Prepared*
MM slash DD slash YYYY
Preparer's Name*
First Last
Preparer's Title*
Phone*
CAPTCHA

Δ

ABOUT US

Pinnacle Construction & Directional Boring Inc. is an Underground Utility Contractor specializing in Horizontal Drilling and Boring. Based in South Carolina.

EXPERT SERVICES

ELECTRIC UTILITY LINE CONSTRUCTION

COMMUNICATIONS & FIBER OPTICS

WATER & SEWER

GAS DISTRIBUTION

GET IN TOUCH

JOIN THE TEAM

REQUEST A QUOTE

LATEST UPDATES

Common Ground Alliance 2019 Technology Report Featuring PCDB

Case Study: Pinnacle Construction & Directional Boring, Inc.’s experience with HDD planning tools Since starting the business in 2001, Erik Carlson, owner of Pinnacle Construction & Directional Boring, Inc., (Pinnacle Construction) believed bore planning was...

South Carolina 811 Announces Q1 Winners for Preferred Partner Program

South Carolina 811 Announces First Quarter Winners of their Inaugural Preferred Partner Program Three industry stakeholders were recognized for their strident efforts made to keep our communities safe when it comes to underground...