Fill and Sign the Petition to Controvert Form

BEFORE THE MISSISSIPPI WORKERS' COMPENSATION COMMISSION CLAIMANT V. NO. EMPLOYERAND CARRIER PETITION TO CONTROVERTMWCC FILE NO. Comes now the claimant and controverts this cause and in support thereof alleges the following: 1. On the day of , 20 , claimant received a compensable i njury while an employee of the captioned employer. 2. Name of Claimant Address Date of Birth Average Weekly Wage 3. Name of Employer Place of Business and Address 4. 5. County and place of accident or illness , County, MS A. Nature of work in which claimant was engaged at time of injury or illness mechanic work B. Description of accident or illness and how it occurred carrying a tire and slipped on wet floor C. Accurately describe the part or parts of body involved or injured, or type of occupational disease, head, neck, back D. Date employer was first notified of injury or illness and name and title of person notified E. Names and Addresses of Witnesses Names and Addresses of Attending Physicians and Hospitals with Dates medical treatment rendered 6. A. Was medical treatment furnished by employer? B. Is medical treatment presently being furnished by employer? Compensation (has) been paid for temporary total disability from 9-07-90 to present at the rate of $ A. Period of Temporary Disability B. Date of maximum medical improvement C. Date able to resume employment D. Nature, degree and extent of permanent disability E. Loss of wage earning capacity, if applicable 7. Injury (did not) result in death; Date of Death, Name, Address, Date of Birth and Relationship of each claimant who was dependent and for whom claim is made is l isted as Exhibit "A", attached hereto, and is made a part hereof by reference. B. Are penalties demanded? If yes, why?