S.C. WORKERS’ COMPENSATION COMMISSION – FIRST REPORT OF INJURY OR ILLNESS  
EMPLOYER (NAME & ADDRESS INCL ZIP)                                                                   CARRIER/ADMINISTRATOR CLAIM     OSHA LOG NUMBER                               REPORT PURPOSE CODE  
                                                                                                     NUMBER  
                                                                                                                                                                                              
                                                                                                     JURISDICTION                    JURISDICTION CLAIM NUMBER 
                                                                                                                                                
                                                                                                     INSURED REPORT NUMBER 
                                                                                                                
                                                                                                     EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)                                    LOCATION # 
                                                                                                                                                                                              
INDUSTRY CODE       EMPLOYER FEIN                                                                                                                                                  PHONE # 
                                                                                                                                                                                              
CARRIER/CLAIMS ADMINISTRATOR  
CARRIER (NAME, ADDRESS, & PHONE #)                     POLICY PERIOD                                                 CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)  
                                                                                                                                
                                                                              TO                     
                                                        
                                                       CHECK IF APPROPRIATE  
                                                         
                                                                  SELF INSURANCE 
CARRIER FEIN                                           POLICY/SELF-INSURED NUMBER                                                                 ADMINISTRATOR FEIN  
                                                                                                                                                             
AGENT NAME & CODE NUMBER  
           
EMPLOYEE/WAGE  
NAME (LAST, FIRST, MIDDLE)                                                         DATE OF BIRTH                SOCIAL SECURITY NUMBER            DATE HIRED                       STATE OF HIRE  
                                                                                                                                                                                              
ADDRESS (INCL ZIP)                                                                 SEX                          MARITAL STATUS                    OCCUPATION/JOB TITLE  
                                                                                    
                                                                                            Male                   Unmarried/Single/Divorced                 
                                                                                            Female                 Married                          
                                                                                                                                                  EMPLOYMENT STATUS 
                                                                                            Unknown                Separated                                 
                                                                                                                   Unknow                         NCCI CLASS CODE 
PHONE                                                                              # OF DEPENDENTS                                                           
                                                                                              
RATE                                        DAY         MONTH                       DAYS                        FULL PAY FOR DAY OF INJURY?                                        YES         NO  
PER:                                                                               WORKED/WEEK  
                                            WEEK        OTHER:                                                  DID SALARY CONTINUE?                                               YES         NO 
  
OCCURRENCE/TREATMENT  
TIME                 AM                       DATE OF INJURY/ILLNESS       TIME OF OCCURRENCE                               AM   LAST WORK DATE                    DATE EMPLOYER NOTIFIED   
EMPLOYEE                                                                                                                                                           DATE DISABILITY BEGAN  
BEGAN WORK           PM                                                    (      )  CANNOT BE  DETERMINED                  PM                                      
                                                                
CONTACT NAME/PHONE NUMBER                        TYPE OF INJURY/ILLNESS                                                                                            PART OF BODY AFFECTED   
                                                                                                                                                                              
DID INJURY/ILLNESS/EXPOSURE                      TYPE OF INJURY/ILLNESS CODE                                                                                       PART OF BODY AFFECTED CODE  
OCCUR ON EMPLOYER’S PREMISES?                                                                                                                                       
 
       YES                                 NO 
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED                           ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED  
                                                                                                        
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR                           WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED  
ILLNESS EXPOSURE OCCURRED                                                                               
           
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED.  DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT                              CAUSE OF INJURY CODE  
DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL                                                                                                              
                                                                                                                                                                              
DATE RETURN(ED) TO WORK                     IF FATAL, GIVE DATE OF DEATH         WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?           YES                                   NO 
                                                                                 WERE THEY USED?                                         YES      
                                                                                                                                                                               NO 
PHYSICIAN/HEALTH  CARE PROVIDER (NAME & ADDRESS)                                 HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)               INITIAL  TREATMENT  
                                                                                                                                             0           No Medical Treatment 
                                                                                                                                             1           MINOR: BY EMPLOYER 
                                                                                                                                             2           MINOR CLINIC/HOSP 
                                                                                                                                             3           EMERGENCY CARE 
                                                                                                                                             4           HOSPITALIZED > 24 HOURS 
                                                                                                                                             5           FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED 
  
OTHER           
WITNESSES (NAME & PHONE #)  
            
DATE ADMINISTRATOR NOTIFIED                                      DATE PREPARED                       PREPARER’S NAME & TITLE                                                       PHONE NUMBER  
                                                                                                                                                                                              
WCC FORM 12A                                                     SEE INSTRUCTIONS FOR IMPORTANT INFORMATION                                                   REPRINTED WITH PERMISSION OF IAIABC        
REV. DATE 04/06 

                                  South Carolina Workers’ Compensation Commission 
                                         1333 Main Street, Suite 500 
                                             P.O. BOX 1715 
                                         Columbia, SC 29202-1715 
                                             803-737-5722 
                                               
                                    EMPLOYER’S INSTRUCTIONS 
                                              
                                    DO NOT ENTER DATA IN SHADED FIELDS 
                                              
  DATES: 
   Enter all dates in MM/DD/YYYY format. 
   
  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. 
   
  CARRIER: 
   The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of 
   the employer of the claimant. 
   
  CLAIMS ADMINISTRATOR: 
   Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering 
   the claim. 
   
  AGENT NAME & CODE NUMBER: 
   Enter the name of your insurance agent and his/her code number if known.  This information can be found on 
   your insurance policy. 
   
  OCCUPATION/JOB TITLE: 
   This is the primary occupation of the claimant at the time of the accident or exposure. 
   
  EMPLOYMENT STATUS: 
   Indicate the employee’s work status.  The valid choices are: 
   Full-Time  On Strike  Unknown   Volunteer 
   Part-Time  Disabled  Apprenticeship Full-Time  Seasonal 
   Not Employed  Retired   Apprenticeship Part-Time  Piece Worker 
   
  DATE DISABILITY BEGAN: 
   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/PHONE NUMBER: 
   Enter the name of the individual at the employer’s premises to be contacted for additional information. 
   
  TYPE OF INJURY/ILLNESS: 
   Briefly describe the nature of the injury or illness, (e.g. Lacerations to the forearm). 
   
  PART OF BODY AFFECTED: 
   Indicate the part of body affected by the injury/illness, (e.g. Right forearm, lower back). 
   
  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. 
  
   WCC FORM 12A    REV. DATE 04/06

                                 South Carolina Workers’ Compensation Commission 
                                            1333 Main Street, Suite 500 
                                                 P.O. BOX 1715 
                                                Columbia, SC 29202-1715 
                                                 803-737-5722 
                                                  
                                 EMPLOYER’S INSTRUCTIONS – cont’d  
                                                   
 ALL EQUIPMENT, MATERIAL 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.  
   
 DATE RETURN(ED) TO WORK:  
   Enter the date following to most recent disability period on which the employee returned to work.   
   
 WCC FORM 12A    REV. DATE 04/06