South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 Post Office Box 1715 Columbia, South Carolina 29202-1715 (803) 737.5675 www.wcc.sc.gov WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: Address: City: Home Phone: Preparer's Name: State: Work Phone: SSN: Employer's Name: Address: Zip: City: Insurance Carrier: State: Zip: Law Firm: Preparer's Phone #: Date of Injury or Illness: __________________ Complete each information blank. Clearly specify when contention are admitted in part and denied in part. The Claimant's answer to the claim respectfully shows: I. Stop payment of compensation. It is admitted denied the Claimant has reached maximum medical improvement and continues to receive temporary compensation payments. It is admitted denied the Claimant's temporary total payments are current. It is admitted denied the Claimant's temporary total payments have been properly stopped as of ___________ (m/d/yyyy) pursuant to Reg. 67-505. II. Address suspension, termination, or reduction of temporary disability payments for any cause. a. At any time pursuant to § 42-9-260(E). b. After the one-hundred-fifty day period has expired pursuant to § 42-9-260(F), R.67-505 and R.67-506. c. Temporary total compensation was suspended, terminated, or reduced without proper order of the Commission. d. Additional compensation and penalties are requested pursuant to Reg. 67-510. The basis for additional compensation and penalty is Determine if compensation is due pursuant to § 42-9-10, § 42-9-20 or § 42-9-30 and, if so, in what amount, based on the following grounds: III. Claimant reached maximum medical improvement on ____________ (m/d/yyyy) (copy of medical report must be attached). It is admitted/denied the Claimant has reached maximum medical improvement. Claimant has has not returned to work. Claimant has has not returned to light duty. a. Permanency is premature at this time. b. Claimant is in need of additional medical care and treatment c. Claimant is entitled to permanent partial disability pursuant to 42-9-30. d. Claimant is entitled to wage loss pursuant to 42-9-20. e. Claimant is entitled to total and permanent disability pursuant to 42-9-10 or 42-9-30(21) and Reg. 67-1802. IV. Request Credit for Overpayment of temporary compensation pursuant to § 42-9-210. It is admitted denied that the Employer/Carrier is due a credit for overpayment. Determine amount of compensation for claims involving a fatality. a. Payment of unpaid balance of compensation when employee dies pursuant to § 42-9-280. b. Amount of compensation for death of employee due to accident pursuant to § 42-9-290. 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. Failure to respond pursuant to Reg. 67-208 B in writing or by submission of a Form 22 may result in ordered mediation pursuant to Reg. 67-1801 B. 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 _________________________________________ Preparer's Signature ______________________________ Title ____ __________________ Date V. VI. Email Questions about the use of this form should be directed to the Judicial Department at 803-737-5675, or judicial@wcc.sc.gov or mediation@wcc.sc.gov Refer to Regulations 67-211, 67-504, 67-505, 67-506, 67-510; and 67-1801. WCC Form # 22 Created 7/15 22 Claimant's Answer to Request for Hearing American LegalNet, Inc. www.FormsWorkFlow.com