14. Has any compensation been paid to date? (YES) (NO) If yes, state amount and give inclusive dates: 12. (YES) (NO) All medical reports that have come into (my) (our) possession have been filed or are being filed It is (admitted) (denied) that the parties were subject to the Mississippi Workers' Compensation Act at the time of Mississippi Workers' Compensation Commission MWCC# ANSWER *If Employer or Carrier Utilizes a Third Party Administrator, Provide Name and Address PRINT OR TYPE NAME ADDRESS EMPLOYER CITY, STATE, ZIP INSURANCE CARRIER The Employer and/or Carrier above named, for answer to the Petition to Controvert herein, respectfully states: 1. 2. 3. 4. 5. 6. 7. 8. then state the average weekly wage, attach hereto a wage statement or state reason not furnished: 9. denied, state temporary disability admitted: to Controvert. If denied, state permanent disability admitted: Controvert. If denied, state loss of wage earning capacity admitted: herewith. If no, list reports not filed and state reason for not filing. 13. Affirmative defenses, special pleadings or matters in dispute (use additional sheet if necessary) This the day of ,20 Name Phone MWCC Form B-5,22 (7/96) G E N E R A L E M P
L O Y E R
A N D
/
O R
C A R R
I
E R
R E S P O N S E CLAIMANT VS D A
T
E It is (admitted) (denied) that claimant sustained an injury or occupational disease on or about the date set forth in the Petition to Controvert. It is (admitted) (denied) that the relationship of employer and employee existed at the time of the alleged injury or occupational disease. alleged injury or occupational disease. If denied, state reason: It is (admitted) (denied) that at the time of the alleged injury or occupational disease the employee was performing service growing out of and in the course of employment. It is (admitted) (denied) that the accident causing the disability for which compensation is claimed arose out of the alleged employment. It is (admitted) (denied) that notice of injury or occupational disease complained of in the Petition to Controvert was received. It is (admitted) (denied) that the employer was insured under the Mississippi Workers' Compensation Act at the time of alleged injury or occupa-donal disease, or was a Self-insurer under the Mississippi Workers' Compensation Act. It is (admitted) (denied) that the average weekly wage as set forth in the Petition to Controvert is correct. If denied It is (admitted) (denied) that claimant was temporarily disabled for the period stated in the Petition to Controvert. If 10. It is (admitted) (denied) the claimant is permanently disabled to the extent and for the period stated in the Petition 11. It is (admitted) (denied) that claimant sustained the loss of wage earning capacity stated in the Petition to (Color Code - White)