MISSISSIPPI WORKERS' COMPENSATION COMMISSION P.O. Box 5300 JACKSON, MISSISSIPPI 39296 Comm. File No. Carrier File No. Carrier APPLICATION FOR LUMP SUM PAYMENT Section 13, Subsection (j) Chapter 354 Laws 1948 1. Name of injured employee (First Name) (Middle Initial) (Last Name) 2. Date of injury 3. Employer NOTE: In answering the following questions, use separate sheet of paper or back of this form, if necessary, to give complete answers. PART I - FOR EMPLOYEE BENEFITS: (Complete Items 1 thru 1 0 and 14 thru 18) 4. Employee's address (City) (No. and Street) (State) Date Disability began 6. 5. Employee's date of birth (Mo.) (Yr.) (Day) If so, give date 7. Have you returned to work? 8. Have you been released by a physician as able to return to work? Date 9. How many weeks' compensation have you received since being released to return to work? - 10. Total amount of compensation received since being released to return to work PART II - FOR DEATH BENEFITS: (Complete Items 1 thru 3 and 11 thru 18) 11. Name of applicant (First Name) (Middle Initial) (Last Name) 12. Applicant's date of birth (Day) (Mo.) (Year) 13. Address of applicant (City) (No. and Street) (State) PART III - FOR EMPLOYEE AND DEATH BENEFITS: 14. For what purpose do you request payment of compensation in one lump sum? 15. List name and date of birth of all members of your immediate family 16. Do any of them have an independent income separate from yours? Source and amount . 17. Do you have an income other than your compensation payments? Source and amount 18. If request is other than Full Lump Sum Payment, state amount requested Phone No. Date (Signature) Form B-19, Revised (5-93)