MISSISSIPPI WORKERS' COMPENSATION COMMISSION JACKSON, MISSISSIPPI CLAIMANT vs. EMPLOYER MWCC FILE NO. INSURANCE CARRIER PETITION TO CONTROVERT Comes now the claimant and controverts this cause and in support thereof alleges the following: day of 1. On the ,20 , claimant received a compensable injury while in the employ of the captioned employer. 2. Name of Claimant S.S. # (Mandatory) Address Date of Birth Occupation Average Weekly Wage 3. Name of Employer Place of Business and Address 4. County and place of accident or illness A. Nature of work in which claimant was engaged at time of injury or illness B. Description of accident or illness and how it occurred C. Accurately describe the part or parts of body involved or injured, or type of occupational disease D. Date employer was first notified of injury or illness and name and title of person notified E. Names and Addresses of Witnesses 5. Names and Addresses of Attending Physicians and Hospitals with Dates medical treatment rendered A. Was medical treatment furnished by employer? B. Is medical treatment presently being furnished by employer? to disability from at 6. Compensation (has) (has not) been paid for 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 7. Injury (did) (did not) result in death; Date of Death 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 is made a part hereof by reference. 8. Are penalties demanded? (Yes) (No) 11 yes, why? 9. Other matters in dispute are as follows: 1 0. (YES) (NO) All medical reports that have come into my possession have been filed or are being filed herewith. day of This the ,20 Signature of Claimant or Representative MWCC Form B-5,11 (Revised 5-93) (Color Code - White) Name and Address of Attorney: