Fill and Sign the Answer Mississippi 497315490 Form

BEFORE THE MISSISSIPPI WORKERS' COMPENSATION COMMISSION       CLAIMANT V. NO.             EMPLOYER AND       CARRIER ANSWER The Employer and/or Carrier above named, for answer to the Petition to Controvert herein, respectfully states: 1. It is (admitted) that claimant sustained an injury or occupational disease on or about the date set forth in the Petition to Controvert. 2. It is (admitted) that the relationship at employer and employee existed at the time of the alleged injury or occupational disease. 3. It is (admitted) that the parties were subject to the Mississippi Workers' Compensation Act at the time of alleged injury or occupational disease. If denied, state reason:       4. It is (admitted) that at the time of the alleged injury or occupational disease the employee was performing service growing out of and in the course of his employment. 5. It is (admitted) that the accident causing the disability for which compensation is claimed arose out of the alleged       payment. 6. It is (admitted) that notice of injury or occupational disease complained of in the Petition to Controvert was received. 7. It is (admitted) that the employer was insured under the Mississippi Workers' Compensation Act at the time of alleged injury or occupational disease, or was a Self - Insurer under the Mississippi Workers' Compensation Act. a. It is (denied) that the average weekly wage as set forth in the Petition to Controvert is correct. If denied state average weekly wage and attach hereto a wage statement or state reason not furnished:       8.       9. It is (admitted) (denied) that claimant was temporarily disabled for the period stated in the Petition to Controvert. If denied state temporary disability admitted. To be determined       . 10. It is (admitted) (denied) that claimant is permanently disabled to the extent and for the period stated in the Petition to Controvert. If denied state permanent disability admitted. To be determined. 11. It is (admitted) (denied) that claimant sustained the loss of wage earning capacity stated in the Petition to Controvert. If denied state loss of wage earning capacity admitted. 12. (YES) (All medical reports that have come into (our) possession have been fled or are being fled herewith. If no, reports not fled and state reason for not fling. 13. Afrmative defenses, special pleadings or matters in dispute (use additional sheet if necessary). See attached "Exhibit A".