Get S.c. Second Injury Fund Reimbursement Request Form - Scsif Sc

Filling out the S.C. Second Injury Fund Reimbursement Request Form can be straightforward if you follow the provided instructions carefully. This guide aims to help you navigate each section of the form to ensure your application is complete and accurate.

Follow the steps to fill out the S.C. Second Injury Fund Reimbursement Request Form online.

1. Click the ‘Get Form’ button to obtain the S.C. Second Injury Fund Reimbursement Request Form and open it in your preferred editing tool.
2. Begin by filling in the 'Second Injury Fund No.' field to identify your case.
3. Next, enter the 'Carrier No.' which corresponds to your insurance provider's identification.
4. Fill in the 'Date of Accident' to specify when the injury occurred.
5. Indicate your 'Compensation Rate' for accurate reimbursement processing.
6. Complete the 'Employee' field with the name of the individual who experienced the injury.
7. For the 'Carrier' field, list the name of the insurance carrier overseeing your claim.
8. Write the 'Employer' name in the appropriate section to indicate who employs the injured individual.
9. In the 'Date of first payment of compensation' field, enter the date when the employee began receiving benefits.
10. Specify the 'Type of Comp Paid' to ensure the correct classification of compensation.
11. For the 'Date for 100% Medical Reimbursement', enter the relevant date, which should be the first day of the 79th week after the accident.
12. Fill in the 'Date Beginning' and 'Date To' fields to outline the period of indemnity payments.
13. In the 'Weeks' section, calculate and insert the number of weeks associated with the compensation.
14. Provide the corresponding 'Amount' for each type of compensation listed: temporary total, temporary partial, permanent partial, permanent total, and death or other. Specify if applicable.
15. Calculate the 'Total Indemnity to date' taking into consideration the specified compensation weeks.
16. Subtract 78 weeks from the total weeks provided to fill in the 'Less 78 weeks' field.
17. Determine the 'Net Reimbursable Indemnity Reimbursement' by subtracting any previous indemnity reimbursements.
18. List the 'Total Indemnity Reimbursement Requested' in the designated section.
19. Provide the 'Total Medical Reimbursement Requested' and ensure to enclose an itemized list as required in the instructions.
20. Finally, calculate the 'Total Reimbursement Requested' to sum both indemnity and medical reimbursements.
21. Certify the accuracy of your information by signing in the 'Signed By' section, including your title and the date.
22. Affix the name and address where the reimbursement should be mailed in the corresponding fields.

Complete and submit your reimbursement request online today for efficient processing.