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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 10/03)
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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