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Get Wcc File #: South Carolina Workers Compensation Commission 1333 Main Street, Suite 500 Post Office

Loyer FEIN #: Claimant's Name: Employer's Name: Address: Address: City: State: Home Phone: Zip: City: Work Phone: Preparer s Name: State: Zip: Insurance Carrier: Law Firm: Preparer s Phone #: Date Attorney Was Hired: Date of Injury: Compensation Rate: Does this conclude the case? Yes No PLEASE CHECK AND COMPLETE ONLY ONE: (A, B, C or D) A. R.67-1205C does not apply to the facts of this case. A % fee of the award or settlement (excluding medical costs) and the costs of.

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