South Carolina > Workers Comp
Employers Answer To Request For Hearing Death Case 53 - South Carolina
| Employers Answer To Request For Hearing Death Case Form. This is a South Carolina form and can be used in Workers Comp . |
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WCC File #: South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5675 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: Preparer's Phone #: ( ) State: Zip: Law Firm: - Complete each information blank. Specify clearly when contentions are admitted in part or denied in part. The employer-insurance carrier in answer to the claim due to the death of respectfully shows: 1. 2. It is admitted (employee's name) denied that the employee sustained an injury on or about the date set forth in the application. admitted denied that both the employer and employee were subject to the Workers' Compensation Act at the It is time in question. The reasons for denial are: 3. It is admitted denial are: denied that the relationship of employer and employee existed at the time in question. The reasons for 4. 5. 6. 7. It is admitted denied that at the time in question the employee was performing services arising out of and in the course of employment. It is It is It is admitted admitted admitted denied that notice of injury was given the employer as specified in the application. denied that the employee was entitled to medical care as a result of the injury. denied that the employee lost compensable time from work and wages for period(s) of: 8. 9. 10. admitted denied that the employee's death resulted proximately from accidental injury arising out of and in the It is (m/d/yyyy). course of employment on It is contended that an average weekly wage of $ as provided by law. Further contentions or grounds of defense are: applies, according to the attached accounting of employee's earnings, I certify that I have served this document pursuant to R.67-212 by delivering a copy to (address) (name), at on the day of , , by first class mail personal service certified mail. Preparer's Signature Title Date Refer to R.67-205 and R.67-601 through R.67-615. Questions about the use of this form may be directed to the Commission's Judicial Department. 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 # 53 Rev. 9/90 53 Employer's Answer to Request for Hearing, Death Case American LegalNet, Inc. www.FormsWorkFlow.com
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