Free Pre-Hearing Statement of Claimant/Employer-Carrier: (Revised 03/15/08) - Mississippi

IMPORTANT NEWS EFFECTIVE MARCH 15, 2008

To avoid scanning and storing extraneous records and those that do not comply with the General Instructions Regarding Prehearing Statement in controverted files, please comply with the following Notice To All Parties In Controverted Claims. The Notice reiterates the General Instructions Regarding Prehearing Statement and adds the following provisions: 1. A party shall not file medical records with the Commission unless submitted as an attachment to a Prehearing Statement or as an exhibit to a motion/response to motion. The Petition to Controvert and Answer no longer require the simultaneous filing of medical records with the Commission. A party shall secure the assigned Judge's permission before filing any single exhibit or attachment that exceeds 50 pages. Please see the following Notice for examples. The Commission will return to sender any records that do not comply with its filing instructions.

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General Instructions Regarding Prehearing Statement

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Complete the PHS in 1 page by following the format of the sample completed form. Supplement as needed by filing an Amended PHS, noting all amendments in bold type. If there is no response to a request for an attachment under ITEM 18., please so state on a sheet of paper titled with the number of that attachment; e.g., if Claimant has not returned to work post-MMI, please so state on a sheet of paper titled Attmt. 3. Answer ITEMS 1-17 with the specific information requested, not "See Attached." Instructions Regarding Exhibits Take all depositions before the date of the evidentiary hearing. Do not offer the Answer or other pleadings already a part of the record as an exhibit. Include surveillance videotapes to be offered during the case-in-chief or impeachment. Paginate each page of each exhibit/attachment as "page ___ of ___ pages" or "3/23." Staple each exhibit separately from the other exhibits. Place exhibits in a binder clip, not a ringed or spiral bound notebook or binder; separate the exhibits with blue sheets of paper. Do not file medical records with the Commission unless submitted as an attachment to a PHS or as an exhibit to a motion/response to motion. - A party seeking to file any single document that exceeds 50 pages (excluding lay and medical depositions) as an attachment to a PHS or as an exhibit to a motion/response to motion must first secure the assigned Judge's permission. Place medical records in chronological order, beginning with the first date of treatment. - Offer records in the order in which the experts treated/evaluated claimant, i.e., offer Dr. McGuire's records as Exhibit 2 and Dr. Vohra's records as Exhibit 3 if claimant saw Dr. McGuire before Dr. Vohra. - File only one copy of the legible, intelligible records that address the contested issues. Generally, hospital records will be limited to ER records, admission/discharge summaries, operative reports, and diagnostic test reports. - Medical records may be attached to the PHS under an unsigned affidavit if the affidavit has been sent to the expert for signature. A signed affidavit must accompany records offered at the hearing absent a stipulation to their admission. Instructions Regarding Witness Lists Identify witnesses by name and address and designate as "will call" or "may call." Identify the reason for calling each witness, i.e., "occurrence witness." Other witnesses, not so listed, will be allowed to testify only for good cause shown. Attach notices of all expert depositions to the Witness List.

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PREHEARING STATEMENTS, INCLUDING ATTACHMENTS, THAT DO NOT COMPLY WITH THE ABOVE REQUIREMENTS WILL BE CONSIDERED INCOMPLETE AND RETURNED TO THE SENDER.

Revised Effective 3-15-2008

PREHEARING STATEMENT OF CLAIMANT (sample completed form) 1. STYLE:
MWCC No. 2232001-H-5687 Cool Hand Luke v. Mary Maloney's Restaurant & Travelers Ins. Co.

2. CLAIMANT DOB: May 30, 1975 3. ADDRESS: 1001 Variation Road; Pass Christian, MS 38677 4 EDUCATION: HS graduate; 3 years of college (English major); no degrees, certifications, licenses 5. PRIOR JOBS/OCCUPATIONS: roughneck, waiter, bartender 6. DATE OF INJURY: April 28, 2004 7. ADMITTED INJURY: YES; NO 8. AWW: $700.00 9. CLAIMANT'S OCCUPATION ON DATE OF INJURY: bartender/manager 10. HOW INJURY OCCURRED and BODY PARTS FOR WHICH CLAIM IS MADE: gathering roses for
patron when slipped and fell in restaurant courtyard, thereby injuring back and left knee

11. DATES and RATES OF TTDB and PDB PAID TO DATE: (1) TTD paid at rate of $341.11 a week from
4-28-04 to 11-30-04; (2) $4,178.60 paid for 7% PPD rating to left knee; PPDB continue to date at rate of $341.11 a week.

12. SURGICAL PROCEDURES PERFORMED and DATES OF SURGERY PER SURGEON: (1) arthroscopy of left knee on June 1, 2004 by orthopedic surgeon Dr. K. A. Porter; (2) laminectomy at L5-S1 on August 20, 2004 by neurosurgeon Dr. W. Faulkner 13. MMI DATE(S); PERMANENT IMPAIRMENT RATINGS and
PERMANENT WORK RESTRICTIONS PER DOCTOR : (1) Orthopedic surgeon Dr. K. A. Porter found Claimant reached MMI from his left knee injury on August 1, 2004 with a 7% PI to the left lower extremity and permanent work restrictions on lifting more than 50 pounds and carrying more than 40 pounds; (2) Neurosurgeon Dr. W. Faulkner found Claimant reached MMI from his back injury on November 30, 2004 with a 5% PI to body as a whole with permanent work restrictions on lifting more than 40 pounds, stooping, and bending frequently.

14. EXPERTS WHO WILL BE DEPOSED and DEPOSITION DATES: Dr. K. A. Porter on January 8, 2005; Dr. W. Faulkner on February 10, 2005 15. ISSUES, INCLUDING AFFIRMATIVE DEFENSES and DISPUTES OVER UNPAID MEDICALS:
Extent of permanent disability attributable to injury; E/C allege intoxication as proximate cause of injury

16. COUNSEL HEREBY VERIFIES TO THE COMMISSION THAT HE/SHE HAS
a. SUPPLEMENTED DISCOVERY RESPONSES PER MRCP RULE 26, b. CONFERRED WITH OPPOSING COUNSEL AND WITH HIS/HER CLIENT REGARDING THE PROSPECTS FOR SETTLING THIS CASE THROUGH MEDIATION, AND c. CONCLUDED THAT MEDIATION WOULD/WOULD NOT EXPEDITE SETTLEMENT. 17. IF NOT, WHY NOT? 18. ATTACHMENTS: Attmts. 1-7 attached.

Atticus Finch , No. 1430, for Claimant
Sign, State Bar No., and Identify Party Represented

6-5-05
Date

Pre-hearing statement, effective 1-2-2006

PREHEARING STATEMENT OF 1. STYLE: 2. CLAIMANT DOB: 4. EDUCATION: 5. PRIOR JOBS/OCCUPATIONS: 3. ADDRESS:

6. DATE OF INJURY: 7. ADMITTED INJURY: YES; NO 8. AWW: 9. CLAIMANT'S OCCUPATION ON DATE OF INJURY: 10. HOW INJURY OCCURRED and BODY PARTS FOR WHICH CLAIM IS MADE: 11. DATES and RATES OF TTDB and PDB PAID TO DATE: 12. SURGICAL PROCEDURES PERFORMED and DATES OF SURGERY PER SURGEON: 13. MMI DATE(S); PERMANENT IMPAIRMENT RATINGS and
PERMANENT WORK RESTRICTIONS PER DOCTOR:

14. EXPERTS WHO HAVE OR WILL BE DEPOSED and DEPOSITION DATES: 15. ISSUES, INCLUDING AFFIRMATIVE DEFENSES and DISPUTES OVER UNPAID MEDICALS: 16. COUNSEL HEREBY VERIFIES TO THE COMMISSION THAT HE/SHE HAS
a. SUPPLEMENTED DISCOVERY RESPONSES PER MRCP RULE 26, b. CONFERRED WITH OPPOSING COUNSEL AND WITH HIS/HER CLIENT REGARDING THE PROSPECTS FOR SETTLING THIS CASE THROUGH MEDIATION, AND c. CONCLUDED THAT MEDIATION WOULD/WOULD NOT EXPEDITE SETTLEMENT. 17. IF NOT, WHY NOT?

18. ATTACH COPIES OF:
1. 2. 3. 4. 5. 6. 7. Final medical report(s) documenting ratings and restrictions as Attmt. 1 (should be 1 page per expert), Work search list identifying post-MMI prospective employers and dates contacted as Attmt. 2, Any post-MMI employers and wage rate/AWW as Attmt. 3, Any vocational/labor market reports available to date as Attmt. 4, Stipulations (especially regarding AWW and MMI) as Attmt. 5, Proposed Exhibits, which must include all medical records affidavits, as Attmt. 6, and Proposed Witness List, which must include all notices of expert depositions, as Attmt. 7.

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Sign, State Bar No., and Identify Party Represented

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Date

***Attach Certificate of Service***

Pre-hearing statement, effective 1-2-2006