Fill and Sign the Contact Usworkers Compensation Commission South Form

Sout h Caroli na Workers ’ Compensatio n Commission 133 3 Mai n Street , Suit e 5 00 P.O . BOX 1715 Columbia, SC 29202-1715 (803) 737-5675 www.wcc.sc.gov PRE - HEARING BRIEF WCC File No:____________ Claimant's Name: Address: City: State: Zip: Home Phone: Work Phone: Preparer's Name: Employer's Name: Address: City: State: Zip: Carrier: Preparer’s Phone #: A claim for workers’ compensation benefits is made based on the following grounds: Injury Illness Repetitive Trauma 1. Compensation Rate : 2. AWW: $ Date of Injury : 3. Type of injury and body part(s): ________________________________________________________________________________________________ 4. Facts in controversy: 5. Legal issues involved: 6. Unusual aspects : 7. Witnesses (designate if expert):* 8. Exhibits: 9. Medical evidence (indicate report pursuant to R.67 - 612; deposition or appearance): 10. Name, address, and specialty, if any, of the treating physician: 11. Impairment rating(s); body part(s); physician and date of opinion: 12. I am amending my Form 50/51 in the following manner: Mediation a.Mediation is requested to be ordered pursuant to Reg. 67-1801 B. b. Mediat io n is required pursuant to Reg. 67-1802. c. Mediation is requested by consent of the Parties pursuant to Reg. 67-1803. d. Mediation has been conducted by a duly qualified mediator and resulted in an impasse. Signature: Date of hearing: Email: Time needed for hearing: Questions about the use of this form should be directed to the Jurisdictional Commissioner. Refer to Regulations 67 - 204 through 67 - 211 and Regulations 67 - 601 through 67 - 615; as well as Regulation 67 - 1801. File this form and proof of service on the opposing party according to R.67 - 611 and R.67 - 212. Do not send medical reports. * Commissioners reserve the right to admit expert witnesses at hearings. WCC Form # 58 Revised 7/15 58 PRE-HEARING BRIEF Questions regarding mediation may be submitted to mediation@wcc.sc.gov.I certify I have served this document pursuant to Reg. 67-211 by delivering a copy to_______________________________________ address __________________________________________________________ on the _____ day of _______________20__ ___, by first class postage certified mail personal service electronic serviceI verify the contents of this form are accurate and true to the best of my knowledge.