South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5739 www.wcc.sc.gov PRE-HEARING BRIEF WCC File No:____________ Claimant's Name: Address: City: Home Phone: Preparer's Name: State: Work Phone: Zip: Employer's Name: Address: City: Carrier: Preparer's Phone #: State: Zip: A claim for workers' compensation benefits is made based on the following grounds: Injury Illness Repetitive Trauma 1. 3. 4. Compensation Rate: 2. AWW: $ Date of Injury: Type of injury and body part(s): ________________________________________________________________________________________________ Facts in controversy: 5. Legal issues involved: 6. 7. Unusual aspects: Witnesses (designate if expert):* 8. Exhibits: 9. Medical evidence (indicate report pursuant to R.67-612; deposition or appearance): 10. Name, address, and specialty, if any, of the treating physician: 11. Impairment rating(s); body part(s); physician and date of opinion: 12. I am amending my Form 50/51 in the following manner: 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. 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 I verify the contents of this form are accurate and true to the best of my knowledge. Signature: Date of hearing: Email: Time needed for hearing: Questions about the use of this form should be directed to the Jurisdictional Commissioner. Refer to Regulations 67-204 through 67-211 and Regulations 67-601 through 67-615; as well as Regulation 67- 1801. File this form and proof of service on the opposing party according to R.67-611 and R.67-212. Do not send medical reports. * Commissioners reserve the right to admit expert witnesses at hearings. PRE-HEARING BRIEF WCC Form # 58 Revised 7/15 58 American LegalNet, Inc. www.FormsWorkFlow.com