Mississippi Workers' Compensation Commission MWCC# *If Employer or Carrier Utilizes a Third Party Administrator, Provide Name and Address ANSWER PRINT OR TYPE GENERAL CLAIMANT VS EMPLOYER INSURANCE CARRIER The Employer and/or Carrier above named, for answer to the Petition to Controvert herein, respectfully states: 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)______________________________ _________________________________________________________________________________________________________ 1. 13. Has any compensation been paid to date? YES ___ NO ___ If yes, state amount and give inclusive dates: _____________________ ____________________________________________________________________________________________________ _________________________________________________________________________________________________________ NAME ADDRESS CITY, STATE, ZIP EMPLOYER AND/OR CARRIER RESPONSE Medical records are no longer to be filed with the Answer to Petition to Controvert. Except as required by Miss. Code Ann. § 71-3-7(1), 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 _____________________, _______________. ___________________________________________ ___________________________________________ DATE ________________________________________________ ________________________________________________ Name ______________________________________ Title MWCC Form B-5,22 (Revised 3-15-2008) ____________________ Phone American LegalNet, Inc. www.FormsWorkFlow.com