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 #: Employer's Name: Address: Claimant's Name: Address: City: Home Phone: Preparer's Name: State: Work Phone: SSN: Zip: City: Insurance Carrier: State: Zip: Law Firm: Preparer's Phone #: The South Carolina Second Injury, in answer to the claim, respectfully shows: 1. 2. It is It is acknowledged acknowledged denied the employee sustained a compensable accident; denied the notice was given to the Second Injury Fund; ________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 3. 4. 5. It is It is a. It is b. It is c. It is 6. 7. It is It is acknowledged acknowledged admitted admitted admitted admitted admitted disability denied the disability claim has been concluded. denied the impairment is: ___________________________________________________________________________ denied the impairment pre-existed. denied the impairment was permanent. denied the impairment is physical. denied the impairment combined with or was aggravated by the subsequent injury. denied the combination/aggravation substantially increased the carrier's liability for both: _____________________________________________________________________________________ medical or _________________________________________________________________________________________________________________________ 8. 9. It is a. It is b. It is c. It is 10. 11. 12. 13. It is It is admitted admitted admitted admitted admitted admitted denied the impairment was a hindrance or obstacle to employment or re-employment. denied the employer had knowledge of the impairment. denied the impairment was unknown to the employee and employer. denied the employee concealed the impairment. denied the subsequent injury would not have occurred "but for" the prior impairment. denied the claim qualifies for reimbursement under S.C. Code Section 42-9-410; _________________________________________________________________________________________________________________________ The Carrier's claim is barred by the Statute of Limitations pursuant to S.C. Code Section 42-15-40; _________________________________________________________________________________________________________________________ Other grounds for denial: _________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 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. _________________________________________ Preparer's Signature ______________________________ Title ____ Email __________________ Date Signature on behalf of the Second Injury Fund Date (m/d/yyyy) Questions about the use of this form should be directed to the Judicial Department at 803.737.5739 or judicial@wcc.sc.gov or mediation@wcc.sc.gov. Refer to Regulation 67-205 through 67-211 and Regulations 67-601 through 67-615; as well as Reg. 67-1801. WCC Form # 55 Revised 07/13 55 Second Injury Fund's Answer to Employer's Request for Hearing American LegalNet, Inc. www.FormsWorkFlow.com