Free B-5,11 - Petition to Controvert: (Revised 3/2008) - Mississippi

MISSISSIPPI WORKERS' COMPENSATION COMMISSION PETITION TO CONTROVERT MWCC #: PLEASE COMPLETE ALL INFORMATION
Claimant Name: Address: City: SSN: Employer Name: Address: City: Insurer Name: State: Date of Birth: Zip: Address: City: Claims Administrator (TPA) Name: Address: City: Phone:

State:

Zip:

State:

Zip:

State:

Zip:

Comes now the claimant and controverts this cause and in support thereof alleges the following: 1. On the __________ day of ____________________, _________, claimant received a compensable injury while in the employ of the captioned employer. 2. Claimant's Occupation: _____________________________ Average Weekly Wage: ________________________________________ 3. County and place of accident or illness: ____________________________________________________________________________ A. Nature of work in which claimant was engaged at the time of injury or illness: __________________________________________ _________________________________________________________________________________________________________ B. Description of accident or illness and how it happened: ____________________________________________________________ _________________________________________________________________________________________________________ C. Accurately describe the part or parts of body involved or injured, or type of occupational disease: ___________________________ _________________________________________________________________________________________________________ D. Date employer first notified of injury or illness and name and title of person notified: _____________________________________ _________________________________________________________________________________________________________ E. Name and addresses of witnesses: ______________________________________________________________________________ _________________________________________________________________________________________________________ 4. Names and addresses of attending physicians and hospitals with dates medical treatment rendered: ______________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ A. Was medical treatment furnished by employer? Yes ___ No ___. B. Is medical treatment presently being furnished by employer? Yes ___ No ___. 5. Compensation has ___ has not ___ been paid for _________________disability from _________________ to _________________at the rate of $ _______________________________. A. Period of temporary disability: ________________________________________________________________________________ B. Date of maximum medical improvement: ________________________________________________________________________ C. Date able to resume employment: ______________________________________________________________________________ D. Nature, degree and extent of permanent disability: _________________________________________________________________ E. Loss of wage earning capacity, if applicable: _____________________________________________________________________ 6. Injury did ___ did not ___ result in death. Date of death (if applicable): ___________________________________________________ Name, address, date of birth and relationship of each claimant who was dependent and for whom claim is made is listed on Exhibit "A", attached hereto, and made a part hereof by reference. 7. Are penalties demanded: Yes ___ No ___. If yes, why? ________________________________________________________________ 8. Other matters in dispute are as follows: _____________________________________________________________________________ _____________________________________________________________________________________________________________ This the _____________ day of __________________________, _______________.

_______________________________________________________ Signature of Claimant or Representative Name, address, phone number, & bar number of attorney:
____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ MWCC Form B-5,11 (Revised 3-15-2008) ____________________________________________________________________

Medical records are no longer to be filed with the Petition to Controvert. A party to a controverted claim shall not file medical records with the Commission unless attached to a Prehearing Statement, or unless relevant to a motion or response to motion and attached thereto as an exhibit.