MISSISSIPPI WORKMEN'S COMPENSATION COMMISSION P. 0. Box 987 JACKSON, MISSISSIPPI 39205 EARLY NOTIFICATION OF SEVERE INJURY Date of Injury Employee's Name Home Telephone # Address Employer Address Carrier Name and Address of Hospital Name and Address of Physician Spinal Cord Injury Major Amputation Type of Injury: Brain Damage Severe Burns, 2nd' and 3rd' Loss of Sight, one or both eyes . Other: explain Remarks Signed Title NOTICE: This notification must be filed with MWCC immediately. THIS DOES NOT REPLACE B-3 Send this report directly to: Mississippi Workmen's Compensation Commission P. 0. Box 987 Jackson, MS 39205 Attention: Rehabilitation Unit MWCC Form R-1 (Adopted 7-82) (Color Code - White)