REPORTING ON-THE-JOB INJURIES
When an employer is notified on an on-the-job injury or illness, he/she must
complete and submit a Workers Compensation - First Report of Injury or Illness (ACORD 4 Form / WCC Form 12-A)
to the State Accident Fund immediately. This submission is critical. The employer, as well as the State
Accident Fund, can be fined for failure to report claims to the Workers' Compensation Commission in a
timely manner. Also, early intervention by a trained claims adjuster is essential to control claim costs
and speed up an employee's return-to-work. Several studies have shown that delays in reporting injuries
have an adverse impact on the cost of a claim and consequently on your premiums.
COMPLETING THE WCC FORM 12-A (First Report of Injury or Illness)
To complete the Workers Compensation - First Report of Injury or
Illness Form (ACORD 4 Form / WCC Form 12-A), follow the instructions provided on
the back of the form. To save time, we recommend you have the following items available
when you begin filling out the form:
- the employee's personnel records.
- the employee's payroll records.
- any medical bills, reports, or statements containing information
on the nature of the accident and/or the extent of the injury.
** NOTE: all claims MUST be submitted using the "Workers Compensation
- First Report of Injury or Illness" ACORD 4 (2/95) / WCC Form 12-A Rev. Date (3/96).
The SC Workers' Compensation Commission will not accept older versions of this form.
SUBMITTING THE WCC FORM 12-A (First Report of Injury or Illness)
By Mail:
When you have completed the Workers Compensation -
First Report of Injury or Illness Form (ACORD 4 Form / WCC Form 12-A), attach to
it any medical bills, reports, or witness statements you have and mail it to:
State Accident Fund
P.O. Box 102100
Columbia, SC 29221-5000
By Internet:
You may submit a Workers Compensation - First Report
of Injury or Illness Form (ACORD 4 Form / WCC Form 12-A) electronically from this
website. Any medical bills, reports, or witness statements will need to be mailed
or faxed separately to:
State Accident Fund
P.O. Box 102100
Columbia, SC 29221-5000
If you are affiliated with a state agency, and the injured employee has lost time
from work due to the injury, explain to them and have them complete a Notice of Election Form containing
the information shown in the example and attach it to the WCC Form 12-A. If you have difficulty in getting
the employee to complete the election form, DO NOT delay submitting the WCC Form 12-A. Simply send
it separately at the earliest possible time.
(Sample Notice of Election Form)