Form B-5,22 - Answer Form - Mississippi Workers' Compensation Commission

Download a blank fillable Form B-5,22 - Answer Form - Mississippi Workers' Compensation Commission in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form B-5,22 - Answer Form - Mississippi Workers' Compensation Commission with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Mississippi Workers’ Compensation Commission
MWCC#
ANSWER
*If Employer or Carrier Utilizes a Third Party Administrator, Provide Name and
Address
PRINT OR TYPE
CLAIMANT
NAME
VS
ADDRESS
EMPLOYER
CITY, STATE, ZIP
INSURANCE CARRIER
The Employer and/or Carrier above named, for answer to the Petition to Controvert herein, respectfully states:
1.
It is admitted ___ denied ___ that claimant sustained an injury or occupational disease on or about the date set forth in the Petition
to Controvert.
2.
It is admitted ___ denied ___ that the relationship of employer and employee existed at the time of the alleged injury or occupational
disease.
3.
It is admitted ___ denied ___ 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 ___ denied ___ that at the time of the alleged injury or occupational disease the employee was performing service
growing out of and in the course of employment.
5.
It is admitted ___ denied ___ that the accident causing the disability for which compensation is claimed arose out of the alleged
employment.
6.
It is admitted ___ denied ___ that notice of injury or occupational disease complained of in the Petition to Controvert was received.
7.
It is admitted ___ denied ___ 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.
8.
It is admitted ___ denied ___ that the average weekly wage as set forth in the Petition to Controvert is correct. If denied then state
the average weekly wage, attach hereto a wage statement or state reason not furnished: __________________________________
________________________________________________________________________________________________________
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: ________________________________________________________________________________
10. It is admitted ___ denied ___ the claimant is permanently disabled to the extent and for the period stated in the Petition to Controvert.
If denied, state permanent disability admitted: ___________________________________________________
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. Affirmative defenses, special pleadings or matters in dispute (use additional sheet if necessary)______________________________
_________________________________________________________________________________________________________
13. Has any compensation been paid to date? YES ___ NO ___ If yes, state amount and give inclusive dates: _____________________
____________________________________________________________________________________________________
_________________________________________________________________________________________________________
Medical records are no longer to be filed with the Answer to Petition to Controvert. A party to a
controverted claim shall not file medical records with the Commission unless attached to a Prehearing
Statement, or unless relevant to a motion or response to motion and attached thereto as an exhibit.
This the ___________ day of _____________________, _______________. ___________________________________________
___________________________________________
________________________________________________
________________________________________________
Name
______________________________________
____________________
Title
Phone
MWCC Form B-5,22 (Revised 3-15-2008)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go