South Carolina > Workers Comp
Second Injury Funds Answer To Employers Request For Hearing 55 - South Carolina
| Second Injury Funds Answer To Employers Request For Hearing 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: - The Second Injury, in answer to the claim, respectfully shows: 1. It is acknowledged denied that the employee sustained a compensable accident; 2. It is acknowledged denied that 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 acknowledged acknowledged admitted admitted admitted admitted admitted denied that the disability claim has been concluded. denied that the impairment is: denied that the impairment pre-existed. denied that the impairment was permanent. denied the impairment is physical. denied that the impairment combined with or was aggravated by the subsequent injury. denied that the combination/aggravation substantially increased the carrier's liability for both: 6. 7. It is It is disability medical or 8. 9. It is a. It is b. It is c. It is admitted admitted admitted admitted admitted admitted denied that the impairment was a hindrance or obstacle to employment or re-employment. denied that the employer had knowledge of the impairment. denied that the impairment was unknown to the employee and employer. denied that the employee concealed the impairment. denied that the subsequent injury would not have occurred "but for" the prior impairment. denied that the claim qualifies for reimbursement under S.C. Code Section 42-9-410; 10. 11. It is It is 12. The Carrier's claim is barred by the Statute of Limitations pursuant to S.C. Code Section 42-15-40; 13. Other grounds for denial: Signature on behalf of the Second Injury Fund Date (m/d/yyyy) WCC Form # 55 Rev. 6/90 55 Second Injury Fund's Answer to Employer's Request for Hearing American LegalNet, Inc. www.FormsWorkFlow.com
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