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MISSISSIPPI WORKERS' COMPENSATION COMMISSION

List of forms currently in use by the Commission

Updated October, 2003.

View the SSN Disclosure Notice.

Forms in green can be filled out using Adobe Acrobat Reader. We will add more of these in the near future. Forms cannot be saved, but they can be filled out and printed for filing with the Commission.

Click the form name to view the form in Adobe .PDF format. If you do not have Adobe Acrobat Reader, click here to download the reader from Adobe's site. You cannot import these forms into Word Perfect or Microsoft Word. They are only readable with Adobe Acrobat Reader.

NOTE: If you have trouble loading the forms in your browser with Acrobat Reader, please refer to this document on the Adobe site for troubleshooting information.

A-2 - Self-Insured Employer Application: (Revised 7/82)

This form should be filled out by those Employers seeking to become approved as Self-Insurers by the Commission, (General Rule 7).

A-24 - Proof of Coverage: (Revised 3/99) Acrobat format, 3-up printable.

Every employer subject to the Mississippi Workers' Compensation Law must file proof of compliance with the insurance provisions of the law. See General Rule 3. This form is currently used only by self-insured employers and groups that do not report to NCCI. It is a 3" X 5" index-card size.

Annual Assessment Report Form(s) for Insurance Companies & Self-Insurers

Every carrier and self-insurer shall file with the commission on or before the first day of March of each year, a statement on the prescribed forms showing the gross claims for compensation and medical services and supplies paid by such carrier or self-insurer during the preceding one-year period ending on the thirty-first day of December.

B-3 - Employer's First Report of Injury or Occupational Disease: (IAIABC IA-1 (8/01)) - Front side (form) only
First Report Instructions - Back side (instructions) only

The IAIABC IA-1, First Report Form has replaced the B-3 Form. The original of this form must be filed with the Commission in all cases involving injuries resulting in lost time in excess of five (5) days and in death cases within ten (10) days after the employer receives notice of injury or death, (Mississippi Code Annotated Section 71-3-67 (1972); Procedural Rule 1).

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

This form is the claimant's application for benefits and request for a hearing, (Procedural Rule 2).

Note: When filing a B-5,11 with us, the original and three copies will need to be provided.

B-5,22 - Answer: (Revised 3/2008)

This form is the response of the employer-carrier to the claimant's Petition to Controvert, (Procedural Rule 4).

B-9,27 - Medical Report: (Revised 6/96)

This form is used by the attending physician for both initial, progress, and final reports. The initial report is made within twenty (20) days of first treatment, periodically thereafter, and upon final treatment of a claimant. Office notes or narrative reports may be attached. (Mississippi Code Annotated Section 71-3-15 (1972); General Rule 9). The HCFA 1500 form will be accepted in lieu of the Commission form if appropriate office/progress notes are attached.

B-18 - Payment Report: (Revised 7/96)

This form is used to report the initial payment to the claimant, any supplemental agreement, and any suspension of payments. The B-18 form is a combination of and replaces the earlier forms B-15, B-16, and B-17. The reverse side of the B-18 contains detailed instructions on its use, (Procedural Rule 16).

B-19 - Application For Lump Sum Payment: (Revised 1/03)

This form is filed by the claimant to request a lump sum payment in accordance with the provisions of Mississippi Code Annotated Section 71-3-37(10) (1972). (General Rule 13; Procedural Rule 15).

B-31 - Report of Payment and Settlement Receipt: (Revised 1/2014)

This form is filed with the Commission within thirty (30) days following final payment of all benefits (Mississippi Code Annotated Section 71-3-37(7) (1972); Procedural Rule 17).

B-52 - Employer's Notice of Controversion: (Instituted 9/93)

The employer or carrier files this form in the event a claim is being denied (Mississippi Code Annotated Section 71-3-37(4) (1972); Procedural Rule 2).

Notice of Coverage (Sample Form)

This form or a facsimile thereof is to be posted at the employer's place of business pursuant to General Rule 8.

R-1 - Early Notification of Severe Injury: (Instituted 7/82)

This form is filed by the employer or carrier immediately with the Commission to give notice of severe injuries. This is used in addition to the First Report of Injury form (IAIABC IA-1). (Mississippi Code Annotated Section 71-3-105 (1972); Procedural Rule 19).

R-2 - Referral for Rehabilitation and Rehabilitation Initial Report: (Revised 9/81)

This form is used by the Commission to refer candidates for rehabilitation to the Vocational Rehabilitation Division of the Mississippi Department of Education and to other rehabilitation suppliers. (Mississippi Code Annotated Section 71-3-105 (1972); Procedural Rule 19).

Additional Forms:

Copy Request Form

Pre-Hearing Statement of Claimant/Employer-Carrier: (Revised 03/15/08) Please click here for a Commission memo regarding the prehearing statement form revision.
Prehearing statements will NOT be accepted via fax or email.

Refer to Procedural Rule 5.

Medical Records Affidavit: (Revised 9/93)

Refer to Procedural Rule 9.

Motion Order: (Revised 2/2007)

Refer to Procedural Rule 22.

Subpoena Duces Tecum: (Revised 6/2013)

This form is the subpoena for the production of documentary evidence. (Procedural Rule 18).

Subpoena for Taking Deposition: (Revised 6/2013)

This form is the subpoena for witness appearance at a deposition. (Procedural Rule 18).

Subpoena of Witness: (Revised 6/2013)

This form is the subpoena for witness appearance and testimony at a hearing set before an Administrative Judge. (Procedural Rule 18).

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