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The WCC 58 form is an essential tool for individuals navigating the workers' compensation process in South Carolina. Designed for pre-hearing submissions, this form captures critical information about the claimant and the employer, including contact details and specifics about the claim. It serves as a structured outline for presenting the grounds for a workers' compensation claim, whether it stems from an injury, illness, or repetitive trauma. The form requires details such as the compensation rate, average weekly wage, and the nature of the injury, along with any facts in controversy and legal issues involved. Additionally, it provides space for listing witnesses, exhibits, and medical evidence, ensuring that all pertinent information is organized and readily accessible. Furthermore, the WCC 58 form addresses mediation requests, allowing parties to indicate if mediation is necessary or has already been attempted. This comprehensive approach not only aids in streamlining the pre-hearing process but also emphasizes the importance of accurate and truthful representation of the claim. For those preparing to submit this form, understanding its components is crucial for ensuring a smooth and effective hearing process.

Preview - Wcc 58 Form

South Carolina Workers’ Compensation Commission

1333 Main Street, Suite 500

P.O. BOX 1715

Columbia, SC 29202-1715

(803) 737-5675

www.wcc.sc.gov

PRE-HEARING BRIEF

WCC File No:____________

Claimant's Name:

 

 

 

 

 

 

 

 

 

Employer's Name:

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

City:

 

 

 

 

State:

 

Zip:

 

City:

 

 

 

State:

 

Zip:

 

Home Phone:

 

 

Work Phone:

 

 

 

Carrier:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preparer's Name:

 

 

 

 

 

 

 

 

 

Preparer’s Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A claim for workers’ compensation benefits is made based on the following grounds:

 

Injury

Illness

Repetitive Trauma

 

 

1.

Compensation Rate:

 

2. AWW:

$

Date of Injury:

3.Type of injury and body part(s): ________________________________________________________________________________________________

4.Facts in controversy:

5.Legal issues involved:

6.Unusual aspects:

7.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.Impairment rating(s); body part(s); physician and date of opinion:

12.I am amending my Form 50/51 in the following manner:

Mediation

a.Mediation is requested to be ordered pursuant to Reg. 67-1801 B.

b.Mediation is required pursuant to Reg. 67-1802.

c.Mediation is requested by consent of the Parties pursuant to Reg. 67-1803.

d.Mediation has been conducted by a duly qualified mediator and resulted in an impasse.

Questions regarding mediation may be submitted to [email protected].

I certify I have served this document pursuant to Reg. 67-211 by delivering a copy to_______________________________________

address __________________________________________________________ on the _____ day of _______________20_____,

by

first class postage

certified mail

personal service

electronic service

I verify the contents of this form are accurate and true to the best of my knowledge.

Signature:

 

 

 

 

Email:

 

 

 

 

 

 

 

 

 

 

Date of hearing:

 

 

Time needed for hearing:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Questions about the use of this form should be directed to the Jurisdictional Commissioner. Refer to Regulations 67-204 through 67-211 and Regulations 67-601 through 67-615; as well as Regulation 67- 1801. 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

58

PRE-HEARING BRIEF

Revised 7/15

 

 

 

Document Specifics

Fact Name Description
Form Purpose The WCC 58 form is used to outline the details of a workers' compensation claim before a hearing.
Governing Body This form is governed by the South Carolina Workers' Compensation Commission.
Contact Information Address: 1333 Main Street, Suite 500, P.O. BOX 1715, Columbia, SC 29202-1715. Phone: (803) 737-5675.
Claimant and Employer Info The form requires the names and addresses of both the claimant and the employer.
Compensation Rate Claimants must provide their compensation rate and average weekly wage (AWW) on the form.
Date of Injury It is necessary to include the date of the injury when filling out the form.
Mediation Options The form includes options for requesting mediation, which can be ordered or agreed upon by the parties.
Legal Issues Claimants must outline any legal issues involved in their case on the form.
Medical Evidence Medical evidence must be indicated, including reports or depositions, as per Regulation 67-612.
Signature Requirement Claimants must sign the form, verifying that the information provided is true and accurate.

Wcc 58: Usage Instruction

Completing the WCC 58 form is a crucial step in the workers’ compensation process. This form requires specific information about the claim, the parties involved, and the issues at hand. Once filled out, it will need to be submitted to the South Carolina Workers’ Compensation Commission, along with proof of service to the opposing party.

  1. Obtain the WCC 58 form from the South Carolina Workers’ Compensation Commission website or office.
  2. Fill in the WCC File Number at the top of the form.
  3. Enter the Claimant's Name and Employer's Name.
  4. Provide the Address, City, State, and Zip code for both the Claimant and the Employer.
  5. List the Home Phone and Work Phone numbers for the Claimant.
  6. Indicate the Carrier information.
  7. Fill in the Preparer's Name and Preparer’s Phone Number.
  8. State the grounds for the claim by selecting one or more of the following: Injury, Illness, or Repetitive Trauma.
  9. Complete the section for Compensation Rate and AWW (Average Weekly Wage). Include the Date of Injury.
  10. Describe the Type of injury and body part(s) affected.
  11. Detail the Facts in controversy.
  12. Outline the Legal issues involved.
  13. Note any Unusual aspects of the case.
  14. List Witnesses, specifying if any are experts.
  15. Indicate any Exhibits that will be presented.
  16. Provide information on Medical evidence, including reports or depositions.
  17. Enter the Name, address, and specialty of the treating physician.
  18. Document any Impairment rating(s), including the body part(s), physician, and date of opinion.
  19. Indicate if you are amending your Form 50/51, and check the appropriate mediation request options.
  20. Certify service of the document by filling in the recipient's name and address, along with the date of service.
  21. Sign the form and provide your Email address.
  22. Specify the Date of hearing and Time needed for hearing.

After completing the form, review it for accuracy. Ensure that all required sections are filled out before submitting it to the appropriate authority. Remember to keep a copy for your records and send proof of service to the opposing party as required.

Learn More on Wcc 58

  1. What is the WCC 58 form?

    The WCC 58 form, also known as the Pre-Hearing Brief, is a document used in South Carolina's workers' compensation process. It is designed to summarize the key elements of a workers' compensation claim before a hearing takes place. This form helps the parties involved present their case clearly and concisely.

  2. Who needs to fill out the WCC 58 form?

    The claimant, or the person filing for workers' compensation benefits, is typically responsible for completing the WCC 58 form. However, the employer or their insurance carrier may also need to provide information related to the claim. It’s important that both parties contribute to ensure all relevant details are included.

  3. What information is required on the WCC 58 form?

    The form requires various pieces of information, including:

    • The names and addresses of the claimant and employer
    • The date of injury and type of injury
    • Details about compensation rates and average weekly wages (AWW)
    • Facts in controversy and legal issues involved
    • Witnesses and exhibits related to the case
    • Medical evidence and information about the treating physician

    This comprehensive information helps set the stage for the hearing.

  4. How do I submit the WCC 58 form?

    The WCC 58 form should be submitted to the South Carolina Workers’ Compensation Commission. You can send it via mail or electronically, depending on the specific instructions provided by the Commission. Be sure to include proof of service to the opposing party as required by the regulations.

  5. What is the purpose of mediation mentioned in the form?

    Mediation is a process where both parties attempt to resolve their dispute with the help of a neutral third party, known as a mediator. The WCC 58 form includes options to request mediation, which can be beneficial in reaching an agreement before the hearing. It can save time and resources for both parties involved.

  6. What should I do if I need to amend my Form 50/51?

    If you need to amend your Form 50/51, the WCC 58 form provides a section to indicate the changes. You can specify the nature of the amendment and whether mediation is requested or required. This ensures that all parties are aware of any updates to the claim.

  7. Can I include medical reports with the WCC 58 form?

    No, you should not send medical reports with the WCC 58 form. The instructions clearly state that medical evidence should be indicated but not submitted with this particular form. Instead, you will need to provide medical evidence during the hearing or in accordance with other regulations.

  8. What happens if I don’t fill out the WCC 58 form correctly?

    Filling out the WCC 58 form incorrectly can lead to delays in your case or even dismissal of your claim. It is crucial to ensure that all information is accurate and complete. If you are unsure about how to fill out the form, consider seeking assistance from a legal professional or the Workers’ Compensation Commission.

  9. Where can I find more information about the WCC 58 form?

    For additional details about the WCC 58 form, you can visit the South Carolina Workers’ Compensation Commission's website. They provide resources, guidelines, and contact information for further assistance. You may also reach out to the Jurisdictional Commissioner for specific questions regarding the form.

Common mistakes

Completing the WCC 58 form accurately is crucial for individuals seeking workers' compensation benefits in South Carolina. However, many people make common mistakes that can hinder their claims. Understanding these errors can help ensure a smoother process.

One frequent mistake is incomplete information. Claimants often leave sections blank or fail to provide detailed descriptions of their injuries or the circumstances surrounding them. For instance, the section asking for the type of injury and body parts affected should be filled out thoroughly. Omitting critical details can lead to delays or even denials of the claim.

Another common error involves incorrect dates. Claimants may accidentally input the wrong date of injury or fail to mention the date they are amending their Form 50/51. Accurate dates are essential for establishing the timeline of events related to the claim. If the dates do not align correctly, it can create confusion and complicate the claim process.

People also often neglect to include medical evidence. The form requires claimants to indicate medical reports or deposition details. Failing to attach or reference this evidence can weaken the claim. Medical documentation is vital for substantiating the injury and demonstrating its impact on the claimant’s life.

Additionally, many individuals overlook the importance of certifying the document properly. The section that requires a signature and verification of the contents is crucial. If this section is not completed correctly, it can lead to the form being rejected. Claimants should ensure they sign and date the form and provide accurate contact information.

Finally, some people make the mistake of not serving the document correctly. The form must be delivered to the opposing party as specified in the regulations. Failure to follow the proper service methods can result in complications or delays in the processing of the claim. It is essential to keep records of how and when the document was served.

By being aware of these common mistakes, individuals can take steps to avoid them. Completing the WCC 58 form with care can significantly enhance the chances of a successful workers' compensation claim.

Documents used along the form

The WCC 58 form is an essential document used in South Carolina's workers' compensation process. Along with this form, several other documents may be required to support a claim. Here is a list of commonly used forms and documents that often accompany the WCC 58.

  • Form 50: This is the official notice of claim for workers' compensation benefits. It provides the basic information about the claimant, the employer, and the nature of the injury or illness.
  • Form 51: This form is used to notify the South Carolina Workers’ Compensation Commission of the acceptance or denial of a claim. It includes details about the claim's status and any decisions made regarding benefits.
  • Form 18: This document serves as a notice of claim and is filed by the injured worker. It outlines the specifics of the injury and the circumstances surrounding it.
  • Form 22: This form provides a wage statement to calculate the Average Weekly Wage (AWW) for the claimant. Accurate wage data is crucial for determining compensation rates.
  • Form 27: This is a request for a hearing. It is filed when there is a dispute regarding the claim, and the parties seek resolution through a formal hearing process.
  • Medical Records: These documents provide evidence of the injury or illness and the treatment received. They are critical for establishing the validity of the claim and the extent of the medical condition.
  • Expert Witness Reports: If applicable, these reports from specialists can help clarify complex medical issues related to the claim. They can be instrumental in supporting the claimant's case.
  • Settlement Agreement: This document outlines the terms of any settlement reached between the parties. It details the compensation agreed upon and any other relevant terms.

Each of these documents plays a vital role in the workers' compensation process. Ensuring that all forms are accurately completed and submitted can significantly impact the outcome of a claim. If you have questions about these documents or the process, seeking assistance is advisable.

Similar forms

The WCC 58 form serves as a pre-hearing brief in South Carolina's workers' compensation system, but several other documents share similar purposes and structures. One such document is the Pre-Trial Statement used in civil litigation. Like the WCC 58, this statement outlines the key facts, legal issues, and witness lists that will be presented at trial. Both documents aim to clarify the positions of the parties involved, helping the court to understand the case better and facilitating a more efficient hearing process.

Another comparable document is the Statement of Claim in personal injury cases. This document initiates a lawsuit by detailing the claimant's allegations and the basis for their claim. Similar to the WCC 58, it requires the claimant to articulate the nature of the injury, the facts surrounding it, and any relevant legal theories. Both documents are crucial in setting the stage for legal proceedings, ensuring that all parties are aware of the issues at hand.

The Discovery Plan is also akin to the WCC 58 form. In civil litigation, this document outlines the scope and method of discovery between parties. Both documents require a listing of evidence, including witness names and types of evidence, to be presented. By doing so, they promote transparency and encourage cooperation between opposing parties, streamlining the legal process.

Similarly, the Case Management Statement used in family law cases shares many characteristics with the WCC 58. This document provides a summary of the issues, proposed resolutions, and timelines for various stages of the case. Both documents aim to facilitate efficient court proceedings by clarifying what is at stake and what needs to be addressed during the hearing.

The Mediation Statement is another document that aligns closely with the WCC 58. This statement is prepared before a mediation session and outlines the parties' positions, the key issues, and any offers made. Like the WCC 58, it serves to inform the mediator and the opposing party of the essential facts and legal arguments, thereby fostering a productive mediation environment.

In administrative law, the Pre-Hearing Conference Statement is quite similar to the WCC 58 form. This document is submitted before a hearing and outlines the issues to be addressed, evidence to be presented, and any stipulations agreed upon by the parties. Both documents serve to prepare for the hearing, ensuring that all relevant information is available to the decision-maker.

The Initial Disclosures required under the Federal Rules of Civil Procedure also share similarities with the WCC 58. These disclosures require parties to provide basic information about their claims and defenses, including witness lists and documents that may be used at trial. Both documents aim to promote fairness and transparency in the legal process by ensuring that all parties are aware of the evidence and arguments that will be presented.

Another document that resembles the WCC 58 is the Plaintiff's Disclosure Statement in federal court cases. This statement provides essential information about the plaintiff's claims, including the basis for the lawsuit and the relief sought. Both documents serve to inform the opposing party and the court about the key aspects of the case, fostering a clearer understanding of the issues involved.

The Notice of Intent to File a Claim is also comparable to the WCC 58. This document informs the opposing party of the claimant's intention to pursue legal action, outlining the basis for the claim and the relief sought. Both documents serve to alert the other party and establish a foundation for further proceedings, ensuring that everyone is on the same page from the outset.

Finally, the Claimant's Brief in unemployment compensation cases shares a similar purpose with the WCC 58. This brief outlines the claimant's arguments and the evidence supporting their claim for benefits. Both documents are designed to present the claimant's case clearly and concisely, allowing the decision-maker to evaluate the merits of the claim effectively.

Dos and Don'ts

When filling out the WCC 58 form, attention to detail is crucial. Here are five things you should and shouldn't do to ensure your submission is accurate and effective.

  • Do provide complete and accurate information in all required fields.
  • Don't leave any sections blank unless instructed otherwise.
  • Do clearly specify the nature of your claim, including the type of injury or illness.
  • Don't include medical reports with your submission, as they are not permitted.
  • Do verify your contact information and that of your attorney or preparer.

Following these guidelines can help streamline the process and avoid potential delays. Accuracy and completeness are key in ensuring your claim is processed efficiently.

Misconceptions

Misconceptions about the WCC 58 form can lead to confusion for those navigating the workers' compensation process in South Carolina. Here are five common misunderstandings:

  • It's only for serious injuries. Many believe that the WCC 58 form is only necessary for severe injuries. In reality, it can be used for any claim related to injuries, illnesses, or repetitive trauma, regardless of severity.
  • Submitting the form guarantees compensation. Some think that filling out the WCC 58 form automatically ensures they will receive benefits. However, the form is just a part of the claims process and does not guarantee approval.
  • All medical reports must be submitted with the form. There is a misconception that all medical evidence needs to accompany the WCC 58 form. In fact, the instructions specify not to send medical reports with the form.
  • It's a complicated document that requires legal assistance. While legal help can be beneficial, many find that the WCC 58 form is straightforward. Claimants can complete it on their own with careful attention to the instructions.
  • Only lawyers can file the form. Some individuals believe that only attorneys can submit the WCC 58 form. In truth, claimants can file it themselves, as long as they follow the proper procedures.

Key takeaways

Filling out the WCC 58 form is an important step in the workers' compensation process in South Carolina. Here are some key takeaways to keep in mind:

  • Accuracy is Crucial: Ensure that all information provided on the form is accurate and complete. Any inaccuracies could delay your case.
  • Understand the Purpose: The WCC 58 form serves as a pre-hearing brief. It outlines the key facts, legal issues, and evidence related to your claim.
  • Compensation Details: Be prepared to include your compensation rate and average weekly wage (AWW). This information is essential for determining benefits.
  • Medical Evidence: Clearly indicate any medical evidence you will present, including reports and the treating physician's details. This is vital for supporting your claim.
  • Mediation Options: Familiarize yourself with the mediation options available. You can request mediation or indicate if it has already occurred.
  • Service of the Document: You must certify that you have served the document to the opposing party. This can be done through various methods, including certified mail.
  • Consult Regulations: Refer to the relevant regulations when filling out the form. Understanding these rules can help you navigate the process more effectively.

By keeping these points in mind, you can approach the WCC 58 form with greater confidence and clarity. Each step is important in ensuring that your case is presented accurately and effectively.