South Carolina > Workers Comp
Pre Hearing Brief 58 - South Carolina
| Pre Hearing Brief Form. This is a South Carolina form and can be used in Workers Comp . |
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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 Claimant's Name: Address: City: Home Phone: Preparer's Name: ( ) State: Work Phone: ( Zip: ) Employer's Name: Address: City: Carrier: Preparer's Phone #: PRE-HEARING BRIEF WCC File No:____________ State: Zip: ( ) - A claim for workers' compensation benefits is made based on the following grounds: Injury Illness Repetitive Trauma 1. 3. 4. Compensation Rate: Type of injury and body part(s): Facts in controversy: 2. AWW: $ Date of Injury: 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. 12. Impairment rating(s); body part(s); physician and date of opinion: I am amending my Form 50/51 in the following manner: ____________________________________________________________ I verify the contents of this form are accurate and true to the best of my knowledge. Signature: Date of hearing: On behalf of Claimant Employer Email: Time needed for hearing: 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. WCC Form # 58 Rev. 9/07 58 PRE-HEARING BRIEF American LegalNet, Inc. www.FormsWorkFlow.com
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