A Service of the Mississippi Lawyers World Wide Web Domain
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A Service of the Mississippi Lawyers World Wide Web Domain |
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| First Report of Injury or Illness | |
| Employer's Intent to Accept or Controvert | |
| Physician's Report | |
| Report of Compensation Paid/Suspension Report | |
| Instructions on Fee and Notary Statement/Application for Certificate of Non-Coverage | |
| Claim for Compensation | |
| Death/PDT Acceptance/Update | |
| Health Notice for Managed Care | |
| Lump Sum Requests/Respondent's Position | |
| Monthly Medical-Only Injury Data | |
| Notice to Employer/Notice to Employee | |
| Notice to Employer/Notice to Employee (Spanish) | |
| Poster of Instructions | |
| Poster of Instructions (Spanish) | |
| Report of Mediation Conference | |
| Supplemental Report | |
| Verification of PTD | |
| Wage Statement |
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| APSS/FSR Application | |
| Policyholder Questionnaire | |
| Accident Prevention Services Annual Report | |
| Accident Prevention Services Worksheet | |
| List of FSR/APSS | |
| Hazard Survey Report | |
| Health & Safety Plan Cover Sheet | |
| Notification of Potential Data Error | |
| Voluntary Drug-Free Workplace Program Application | |
| Voluntary Drug-Free Workplace Program Annual Insurance Carrier Report |
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| Individual Self-Insurer Application | |
| Group Self-Insurance Application | |
| Application for Membership in a Group |
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| Third-Party Administrator Application/Registration |
-- PLEASE NOTE --
The following forms are provided for informational purposes only. These forms are initiated by the commission and sent to the appropriate parties for completion.
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| Loss Summary Data Report | |
| Loss Summary Data Report - Itemized Listing | |
| Workers' Compensation Premium Tax Report | |
| Instructions for Completing Premium Tax Report |
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| Claimant Information Update/Change of Address | |
| Guardianship Affidavit (Court-Appointed, Non-Minor) | |
| Power of Attorney Notice & Affidavit | |
| Surviving Spouse Notice & Affidavit | |
| Guardian's Affidavit - Dependent Child(ren) | |
| Affidavit for Dependents Other Than Spouse or Child | |
| Certification of Acceptance | |
| Authorization for Release of Student Information |
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