MISSISSIPPI WORKERS' COMPENSATION COMMISSION Injury Date MWCC FILE NO. / / Disability Date Carrier File No. / / NOTICE OF FIRST PAYMENT OF T.T.D. BENEFITS SUPPLEMENTAL AGREEMENT AS TO COMPENSATION NOTICE OF SUSPENSION OF PAYMENT Type of NOTICE: I. GENERAL INFORMATION Insurance Carrier Name and Address (Include City, State, and Zip) Employee Name and Address (Include City, State, and Zip) Birth Date FEIN: SSN: / / - - Employer Name and Address (Include City, State, and Zip) Claim Administrator Name and Address (Include City, State, and Zip) FEIN: FEIN: II. NOTICE OF FIRST PAYMENT: Please take notice that payment of compensation for temporary total disability has begun and will continue until further notice: Date of First Check: Average Weekly Wage: $ / / to Period Paid From: / / / / Compensation Rate: First Check Amount: $ $ III. SUPPLEMENTAL AGREEMENT: Please take notice that we agree, subject to applicable statutory limitations, to the following: TEMPORARY TOTAL: Employee again became temporarily totally disabled on , and is now receiving benefits therefor at / / per week and continuing until further notice. the rate of $ / TEMPORARY PARTIAL: Employee first became, or again became temporarily partially disabled on , and is now receiving / benefits therefor at the rate of 2/3 of the decrease in wage earning capacity and continuing until further notice. PERMANENT TOTAL: Employee is entitled to compensation for permanent total disability commencing on , at the rate of / / weeks. per week, and continuing for a period of $ % loss of PERMANENT PARTIAL: Employee is entitled to compensation for the , commencing on per week, and continuing for a period of weeks. , at the rate of $ / / DEATH: Dependents are entitled to death benefits commencing on , at the combined rate of $ per / / week. Said benefits will continue for the statutorily prescribed period. (Itemize below - attach additional page if necessary). OTHER: Death: Name of Beneficiary and Address Relation Date of Birth Weekly Rate a. $ b. $ c. $ d. $ IV. NOTICE OF SUSPENSION OF PAYMENT: Please take notice that the payment of compensation has been suspended, and was last paid on per week for the following: , at the rate of $ / / PERMANENT PARTIAL TEMPORARY PARTIAL PERMANENT TOTAL TEMPORARY TOTAL DEATH OTHER Reason compensation was suspended: Employee returned to work at weekly wage of $ Average weekly wage at time of injury was $ I certify that a copy of this Form has been furnished to the above named employee, beneficiary, or representative / / Title: Phone: Name: MWCC Form B-18 (Revised 7-96) Reverse Side to Form B-18 This Form (B-18) combines former MWCC forms B-15, B-16 and B-17. Procedural Rule 16 of the Commission is intended to apply to the use of this form as though Form B-18 was referenced therein. The use of this form is not intended to alter any rights of parties under the Workers' Compensation Act, but is intended solely to improve the processing and administering of claims by the Commission. This Form has been developed by the Commission pursuant to Mississippi Code Annotated Sections 71-3-37(3) and 71-3-85(3), (6) (1972), as amended, and may be used in lieu of forms B-15, B-16 and B-17. PRIOR APPROVAL OF THIS OR ANY OTHER FORM USED FOR SUCH PURPOSES IS NOT REQUIRED IN ORDER FOR PAYMENT OF BENEFITS TO BEGIN OR CONTINUE. THE EMPLOYER/CARRIER'S OBLIGATION TO BEGIN OR CONTINUE PAYING BENEFITS IS NOT SUSPENDED PENDING COMMIS- SION REVIEW OF THIS OR ANY OTHER FORM USED FOR THE SAME PURPOSE. THE COMMISSION WILL NOTIFY THE EMPLOYER/CARRIER IF THERE IS A MISTAKE, DEFICIENCY OR OTHER PROB- LEM SO THAT CORRECTIVE ACTION CAN BE TAKEN BY THE EMPLOYER/CARRIER. Part I of this Form (General Information) should be completed in full in all cases. Part II of this Form (Notice of First Payment) should be used when making the first payment for temporary total disability benefits. Mississippi Code Annotated Section 71-3-37(3) (1972), as amended; Procedural Rule 16. I Part III of this Form (Supplemental Agreement) should be used when making the first payment of temporary partial disability benefits, permanent disability benefits (partial or total), death benefits, head or facial disfigurement, maintenance payments in connection with vocational rehabilitation, accelerated perma- nent disability benefits, and upon the resumption of temporary disability benefits for an additional period. Mississippi Code Annotated Sections 71-3-19, -37(3) (1972), as amended; Procedural Rule 16; General I Rule 13. Part IV of this Form (Notice of Suspension) should be used and filed immediately with the Commission upon suspension of payment of compensation benefits. Mississippi Code Annotated Section 71-3-37(3) (1972), as amended; Procedural Rule 16. THE ORIGINAL OF THIS FORM ONLY MUST BE FILED WITH THE COMMISSION, AND A COPY MUST ALSO BE MAILED TO OR FURNISHED TO THE EMPLOYEE, BENEFICIARY, OR REPRESENTA- TIVE BY THE EMPLOYER/CARRIER.