South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 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 contentions are admitted in part or denied in part. The Employer-insurance Carrier in answer to the claim due to the death of (employee's name) respectfully shows: 1. 2. It is admitted denied the employee sustained an injury on or about the date set forth in the application. 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: 3. It is admitted denied the relationship of employer and employee existed at the time in question. The reasons for denial are: 4. 5. 6. 7. It is It is It is It is admitted admitted admitted admitted denied at the time in question the employee was performing services arising out of and in the course of employment. denied notice of injury was given the employer as specified in the application. denied the employee was entitled to medical care as a result of the injury. denied the employee lost compensable time from work and wages for period(s) of: 8. It is admitted denied the employee's death resulted proximately from accidental injury arising out of and in the course of employment on ____________(m/d/yyyy). 9. 10. It is contended that an average weekly wage of $__________ applies, according to the attached accounting of employee's earnings, as provided by law. Further grounds of claim: 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 first class postage certified mail personal service. _____________________________________ Preparer's Signature ______________________________ Title __________________ Date 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 67-205 through 67-211, 67-215, Regulations 67-601 through 67-615; and Regulations 67-901-905 as well as Reg. 67-1801. WCC Form # 53 Revised 7/13 53 Employer's Answer to Request for Hearing, Death Case American LegalNet, Inc. www.FormsWorkFlow.com