Mississippi > Workers Compensation
Prehearing Statement Of Claimant Or Employer-Carrier - Mississippi
| Prehearing Statement Of Claimant Or Employer-Carrier Form. This is a Mississippi form and can be used in Workers Compensation . |
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MISSISSIPPI WORKERS COMPENSATION COMMISSION MWCC NO. _____________________ ________________________________ CLAIMANTVS. ________________________________ EMPLOYERAND ________________________________ CARRIER STATEMENT OF CLAIMANT/EMPLOYER-CARRIERGNIRAEHPRE FAILURE TO FILE A COMPLETED STATEMENT MAY RESULT IN DISMISSALGINARHE PRE OF THE CLAIM OR OTHER SANCTIONS. NO HEARING WILL BE SET UNTIL A STATEMENT HAS BEEN FILED BY ALL PARTIESGRINHEACOMPLETED PRE I. Please list the contested issues (TT all that apply): ____ 1. Whether a compensable injury occurred as alleged in the Petition to Controvert; ____ 2. The amount of claimants average weekly wage on the date of injury; ____ 3. Existence/extent of temporary disability attributable to the injury; ____ 4. Existence/extent of permanent disability attributable to the injury; ____ 5. Reasonableness/necessity of certain medical treatment; ____ 6. Any other issues in dispute (please list): ____________________________________________________________ II. Please list the stipulations (TT all that apply): ____ 1. Average weekly wage of claimant on date of injury was $ _____________; (If average weekly wage not stipulated, employer/carrier must attach wage s tatement) ____ 2. Dates and amounts of disability benefits already paid: Temporary total from __________ to __________ at $ __________ per week; Temporary partial from _________ to __________ at $ __________ per week; Permanent partial from _________ to __________ at $ __________ per week; Permanent total from __________ to __________ at $ __________ per week; ____ 3. All medical services have been provided; <<<<<<<<<********>>>>>>>>>>>>> 2 ____ 4. Date of maximum medical improvement is _______________; ____ 5. Other stipulations (please list): _____________________________________________________________III. Medical Reports (TT all that apply): ____ 1. Current medical reports have been previously filed with the Commission and furnished to the opposing parties. ____ 2. CurrenteaH medical reports are included by attachment to the Pre-ginr Statement.IV. Lay Witnesses: Please provide the name and address of each lay witness who may be called by you to testify at the hearing, except those to be called solely for impeachment or rebu ttal purposes: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _V. Expert Witnesses: Please provide the name and address of each expert witness whose opinion(s) may be used by you, and for each such witness state whether: 1. OpinionHe to be offered by affidavit and records which are attached to Pre-argin Statement, or were previously filed with the Commission on ___________; 2. Opinion to be offered by deposition, transcript of which is attached to Pre- Statement or was previously filed with the Commission onginarHe ______________; 3. Opinion to be offered by deposition which is noticed for _______________ (a copy of the notice of deposition must be attached); 4. Expert witness will testify in person at the hearing.THIS STATEMENT WILL NOT BE CONSIDERED COMPLETE UNLESSGINARHE PREALL AFFIDAVITS AND RECORDS, DEPOSITIONS OR NOTICES OF DEPOSITION,FOR EACH EXPERT WITNESS HAVE EITHER BEEN PREVIOUSLY FILED WITH THE STATEMENTGINARHECOMMISSION OR ATTACHED TO THE PRE-VI. Exhibits: Please list all exhibits which may be offered by you, except those intended solely for impeachmentHe or rebuttal, and for each such exhibit state whether it is attached to the Pre-argin Statement, or was previously filed with the Commission on ______________ ____.<<<<<<<<<********>>>>>>>>>>>>> 3VII. Settlement Negotiations (TT one that applies): ____ 1. The parties have conducted serious settlement negotiations. ____ 2. The parties have not conducted serious settlement negotiations. Please explain:_______________________________________VIII. Length of Hearing: The Administrative Judge should allot _________ hours for the hearing. (Be realistic and reasonable; consider all potential witnesses and the amount of time needed to effec tively examine and cross- examine each, and any other issues to be addressed at the hearing) IX. Discovery Responses (TT one that applies): ____ 1. All discovery responses, including but not limited to claimants most re cent job search efforts and list of witnesses, have been timely supplemented as necessary. ____ 2. All discovery responses have not been timely supplemented as necessary. Please explain: __________________________________________________X. Other Matters: Please list any other matters which you feel may aid in or affect the disposition of this case: ________________________________________________________________________ _________________________________________________________________________ Respectfully submitted, this the _______ day of _____________________, _____________ . ____________________________________ (signature)Name of Attorney Mississippi Bar Number Address Telephone/Fax/E-Mail ***ATTACH CERTIFICATE OF SERVICE*** Statement (Rev. 2/1999)ginraeHMWCC Form - Pre-
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