Fill and Sign the South Carolina Workers Compensation Commission Scgov Form

Refer to R.67-204 through R.67- 210 an d R.67-601 through R.67-615. Refer to R. 67-1801 for mediation. Question s about the use of this form may be directe d to the Commission’s Judicial Department at 803- 737 -5675 or jud icial @wcc.sc.gov or mediation@wcc.sc.gov . Pursuant to R.67-606, a Form 20 mu st be file d with the Claims Department at least 30 days from the date of filin g thi s form. WCC Form # 51 Revised 07/1 5 51 Employer’s Answe r to Request for Hearing South Carolina Workers’ Compensatio n Commission 1333 Main Street, Suite 500 ● Post Office Box 1715 Columbia, South Carolina 29202-1715 (803) 737-5 675 www.wcc.sc.gov WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: SSN: Address: City: State: Zip: Home Phone: Work Phone: Date of Injury: Employer's Name: Address: City: State: Zip: Insurance Carrier: Preparer’s Name: Law Firm: Preparer’s Phone #: Date of Injury or Illness: ________________ Estimated time for hearing: Complete each information blank. Clearly specify when contentions are ad mitted in part and denied in part. The Employer/Carrier in answer to the claim, respectfully shows: 1. It is Admitted Denied the employee sustained an injury or illness on or about the date set forth in the Form 50. The reasons for denial are: 2. It is Admitted Denied both the employer and employee were subject to the Workers’ Compensation Act at the t ime in question. The reasons for denial are: 3. It is Admitted Denied the relationship of employer and employee existed at the time in question. The reasons for denial are: 4. It is Admitted Denied at the time in question the employee was performing services arising out of and in the course of employment. The reasons for denial are: 5. It is Admitted Denied notice of injury was given the employer. The reasons for denial are : 6. It is Admitted Denied the employee Needs Is Entitled to Additional medical care as a result of injury or illness. The reasons for denial are: 7. It is Admitted Denied the employee is entitled to temporary total disability for the period(s) o f : _____________________________________ 8. It is Admitted Denied the employee is permanently disabled. The reasons for denial are: 9. It is Admitted Denied the employee has serious disfigurement. 10. It is contended that an average weekly wage of $ ___________ applies, according to attached Form 20 as provided by law. 11. Further contentions , grounds of defense, or unusual aspects are: Mediation a.Mediation is requested to be ordered pursuant to Reg. 67-1801 B. b. Mediation 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. 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 service I verify the contents of this form are accurate and true to the best of my knowledge. __________________________________________ ________________________________ ___________________________________ _________________ Preparer’s Signature Title Email Date