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S MWCC # CARRIER FILE # (2) SOCIAL SECURITY 0 (3) DATE OF INJURY OR DEATH (4) DATE DISABILITY BEGAN (5) DATE MAXIMUM MEDICAL IMPROVEMENT (6) DATE RETURNED TO WORK 17) DATE OF FINAL PAYMENT Mississippi Workers' Compensation Commission NOTICE OF FINAL PAYMENT PRINT OR TYPE NAME AND ADDRESS - (INCLUDE CITY, STATE and ZIP) (1) (9) INSURANCE CARRIER NAME & SERVICING CO. (if applicable) (8) EMPLOYER NAME AND ADDRESS - (INCLUDE CITY, STATE and ZIP) Compensation payments were made as follows: NOTICE: If salary paid in lieu of compensation, report below the amount of compensation which would have otherwise been due. $ (11) Rate of Weekly Compensation $ (10) Average Weekly Wage: B. DEATH PAYMENTS A. DISABILITY PAYMENTS Days (itemize at 26 below) Weeks (16) $ Days Temporary Total Weeks $ (12) (17) Lump Sum to Spouse $ Days Temporary Partial $ Weeks (13) $ (18) Funeral Expenses $ (19) Second Injury Fund $ Days Permanent Partial Weeks (14) % loss to Weeks (15) Days Permanent Total $ Total Disability Payments $ Total Death Payments $ D. OTHER PAYMENTS C. SETTLEMENT PAYMENTS (20) Lump Sum $ (23) Total Medical Expenses $ (21) Compromise $ (24) Rehabilitation Expenses $ . (25) Other (Specify) $ (22) Third Party: (Attach order if not approved by MWCC a. Amt. reimbursed for comp. previously paid (Subtract reimbursements) $ ) b. Amt. credited against future liability $ Total Settlement Payments $ TOTAL PAYMENTS (A + B + C* + D) *If C is a negative amount, subtract from total $ (26) Dependents and Spouse Payments Itemized Below (attach separate page if necessary) Weeks Days Rate Total Name and Relationship a. $ b. $ $ c. d. $ (27) If full compensation was not paid, explain: (attach separate page if necessary) NOTICE TO EMPLOYEE OR BENEFICIARY This is NOT a release of the employer's or the insurance carrier's workers' compensation liability. It is a statement of workers' compensation benefits already paid. If no further workers' compensation benefits are provided within one (1) year from the date this form is properly filed with the Commission, the right to any further such benefits may be barred by the apRlicable statute of limitations and this claim finally closed. Exceptions may apply for incompetents or minors. If you incur additional loss of time from work, additional medical expense, or other additional expense, due to this injury, you should immediately contact your employer, the insurance carrier, or the Mississippi Workers' Compensation N
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E PHONE #: / / Employee's Signature: Date / / Date Prepared by: (or representative or beneficiary) MWCC Form B-31 (7/96) (Color Code - Blue) ( G
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