Form B-5,11 - Petition To Controvert - Mississippi Workers' Compensation Commission

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MISSISSIPPI WORKERS’ COMPENSATION COMMISSION

PETITION TO CONTROVERT

PLEASE COMPLETE ALL INFORMATION

MWCC #:

Claimant Name:

Insurer Name:

Address:

City:

State:

Zip:

Address:

SSN:

Date of Birth:

City:

State:

Zip:

Employer Name:

Claims Administrator (TPA) Name:

Address:

City:

State:

Zip:

City:

State:

Zip:

Phone:

Comes now the claimant and controverts this cause and in support thereof alleges the following:

1. On the __________ day of ____________________, _________, claimant received a compensable injury while in the employ of the

captioned employer.

2. Claimant’s Occupation: _____________________________ Average Weekly Wage: ________________________________________

3. County and place of accident or illness: ____________________________________________________________________________

A. Nature of work in which claimant was engaged at the time of injury or illness: __________________________________________

_________________________________________________________________________________________________________

B. Description of accident or illness and how it happened: ____________________________________________________________

_________________________________________________________________________________________________________

C. Accurately describe the part or parts of body involved or injured, or type of occupational disease: ___________________________

_________________________________________________________________________________________________________

D. Date employer first notified of injury or illness and name and title of person notified: _____________________________________

_________________________________________________________________________________________________________

E. Name and addresses of witnesses: ______________________________________________________________________________

_________________________________________________________________________________________________________

4. Names and addresses of attending physicians and hospitals with dates medical treatment rendered: ______________________________

_____________________________________________________________________________________________________________

A. Was medical treatment furnished by employer? Yes ___ No ___.

B. Is medical treatment presently being furnished by employer? Yes ___ No ___.

5. Compensation has ___ has not ___ been paid for _________________disability from _________________ to _________________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: _____________________________________________________________________

6. Injury did ___ did not ___ result in death. Date of death (if applicable): ___________________________________________________

Name, address, date of birth and relationship of each claimant who was dependent and for whom claim is made is listed on Exhibit “A”,

attached hereto, and made a part hereof by reference.

7. Are penalties demanded: Yes ___ No ___. If yes, why? ________________________________________________________________

8. Other matters in dispute are as follows: _____________________________________________________________________________

_____________________________________________________________________________________________________________

This the _____________ day of __________________________, _______________.

_______________________________________________________

Signature of Claimant or Representative

Name, address, phone number, & bar number of attorney:

____________________________________________________________________

MWCC Form B-5,11 (Revised 3-15-2008)

____________________________________________________________________

Medical records are no longer to be filed with the 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.