MISSISSIPPI WORKERS'COMPENSATION COMMISSION Post Office Box 5300, Jackson, Mississippi 39296-5300 EMPLOYER'S NOTICE OF CONTROVERSION MWCC FILE NUMBER CARRIER FILE NUMBER EMPLOYEE CLAIMANT SOC. SEC. NO. NATURE OF INJURY ADDRESS DATE OF BIRTH SEX STATE ZIP INJURY DATE CITY INSURANCE CARRIER EMPLOYER ADDRESS CITY ZIP STATE CITY STATE ZIP Pursuant to Section 71-3-37(4) of the Mississippi Workers' Compensation Act, the above named employer controverts the referenced employee's right to workers' Compensation upon the following grounds: . I hereby certify that a copy of this notice has been served, by mail or personal delivery, to the above named employee at the most current address which can be determined by diligent inquiry or to his or her attorney, if represented. Dated: Signature of Employer/Carrier Representative Title Address City State Zip Telephone number: MWCC Form B-52 (1993) AGE ADDRESS