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 #: SSN: Employer's Name: Address: City: Insurance Carrier: State: Zip: Claimant's Name: Address: City: Home Phone: Date of Injury: Preparer's Name: State: Work Phone: Zip: Law Firm: Preparer's Phone #: Date of Injury or Illness: ________________ Estimated time for hearing: Complete each information blank. Clearly specify when contentions are admitted in part and denied in part. The Employer/Carrier in answer to the claim, respectfully shows: 1. 2. 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: Denied both the employer and employee were subject to the Workers' Compensation Act at the time in question. The reasons for It is Admitted denial are: It is Admitted 3. 4. Denied the relationship of employer and employee existed at the time in question. The reasons for denial are: Denied at the time in question the employee was performing services arising out of and in the course of employment. The It is Admitted reasons for denial are: It is Admitted 5. 6. Denied notice of injury was given the employer. The reasons for denial are: Denied the employee Needs Is Entitled to Additional medical care as a result of injury or illness. The reasons for It is Admitted denial are: It is It is Admitted Admitted 7. 8. Denied the employee is entitled to temporary total disability for the period(s) of : _____________________________________ 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. b. c. d. Mediation Mediation Mediation Mediation is requested to be ordered pursuant to Reg. 67-1801 B. is required pursuant to Reg. 67-1802. is requested by consent of the Parties pursuant to Reg. 67-1803. 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: electronic service first class postage certified mail personal service I verify the contents of this form are accurate and true to the best of my knowledge. __________________________________________ Preparer's Signature ________________________________ Title ___________________________________ _________________ Email Date Refer to R.67-204 through R.67-210 and R.67-601 through R.67-615. Refer to R. 67-1801 for mediation. Questions about the use of this form may be directed to the Commission's Judicial Department at 803-737-5675 or judicial@wcc.sc.gov or mediation@wcc.sc.gov. Pursuant to R.67-606, a Form 20 must be filed with the Claims Department at least 30 days from the date of filing this form. WCC Form # 51 Revised 07/15 51 American LegalNet, Inc. www.FormsWorkFlow.com Employer's Answer to Request for Hearing