Selected state specific workers' compensation forms are now availabe for our subscribers and can be accessed here.

For our previous customers, a link to the old Omniform format forms can be found here and near the bottom of this page. Please be advised that all updates will now be in Adobe pdf format only.

• A-2 - Self-Insured Employer Application: (Revised 7/82) 

This form should be filled out by those Employers seeking to become approved as Self-Insurers by the Commission, (General Rule 7).
 
• A-24 - Proof of Coverage: (Revised 3/99) Acrobat format, 3-up printable. 

Every employer subject to the Mississippi Workers' Compensation Law must file proof of compliance with the insurance provisions of the law. See General Rule 3. This form is currently used only by self-insured employers and groups that do not report to NCCI. It is a 3" X 5" index-card size.
 
• B-3 - Employer's First Report of Injury or Occupational Disease: (IAIABC IA-1 (8/01)) - Front side (form) only. First Report Instructions - Back side (instructions) only 

The IAIABC IA-1, First Report Form has replaced the B-3 Form. The original of this form must be filed with the Commission in all cases involving injuries resulting in lost time in excess of five (5) days and in death cases within ten (10) days after the employer receives notice of injury or death, (Mississippi Code Annotated Section 71-3-67 (1972); Procedural Rule 1).
 
• B-5,11 - Petition to Controvert: (Revised 1/99) 

This form is the claimant's application for benefits and request for a hearing, (Procedural Rule 2). 
Note: When filing a B-5,11 with the Commission, the original and three copies will need to be provided.
 
• B-5,22 - Answer: (Revised 7/96) 

This form is the response of the employer-carrier to the claimant's Petition to Controvert, (Procedural Rule 4).
 
• B-9,27 - Medical Report: (Revised 6/96) 

This form is used by the attending physician for both initial, progress, and final reports. The initial report is made within twenty (20) days of first treatment, periodically thereafter, and upon final treatment of a claimant. Office notes or narrative reports may be attached. (Mississippi Code Annotated Section 71-3-15 (1972); General Rule 9). The HCFA 1500 form will be accepted in lieu of the Commission form if appropriate office/progress notes are attached.
 
• B-18 - Payment Report: (Revised 7/96) 

This form is used to report the initial payment to the claimant, any supplemental agreement, and any suspension of payments. The B-18 form is a combination of and replaces the earlier forms B-15, B-16, and B-17. The reverse side of the B-18 contains detailed instructions on its use, (Procedural Rule 16).
 
• B-19 - Application For Lump Sum Payment: (Revised 1/03) 

This form is filed by the claimant to request a lump sum payment in accordance with the provisions of Mississippi Code Annotated Section 71-3-37(10) (1972). (General Rule 13; Procedural Rule 15).
 
• B-31 - Report of Payment and Settlement Receipt: (Revised 10/03) 

This form is filed with the Commission within thirty (30) days following final payment of all benefits (Mississippi Code Annotated Section 71-3-37(7) (1972); Procedural Rule 17).
 
• B-52 - Employer's Notice of Controversion: (Instituted 9/93) 

The employer or carrier files this form in the event a claim is being denied (Mississippi Code Annotated Section 71-3-37(4) (1972); Procedural Rule 2).
 
• Notice of Coverage (Sample Form) 

This form or a facsimile thereof is to be posted at the employer's place of business pursuant to General Rule 8.
 
• R-1 - Early Notification of Severe Injury: (Instituted 7/82) 

This form is filed by the employer or carrier immediately with the Commission to give notice of severe injuries. This is used in addition to the First Report of Injury form (IAIABC IA-1). (Mississippi Code Annotated Section 71-3-105 (1972); Procedural Rule 19).
 
• R-2 - Referral for Rehabilitation and Rehabilitation Initial Report: (Revised 9/81) 

This form is used by the Commission to refer candidates for rehabilitation to the Vocational Rehabilitation Division of the Mississippi Department of Education and to other rehabilitation suppliers. (Mississippi Code Annotated Section 71-3-105 (1972); Procedural Rule 19).

• Pre-Hearing Statement of Claimant/Employer-Carrier: (Revised 5/99) 

Refer to Procedural Rule 5.
 
• Medical Records Affidavit: (Revised 9/93) 

Refer to Procedural Rule 9.
 
• Motion Order: (Revised 9/93) 

Refer to Procedural Rule 22.
 
• Subpoena Duces Tecum: (Revised 7/2000) 

This form is the subpoena for the production of documentary evidence. (Procedural Rule 18).
 
• Subpoena for Taking Deposition: (Revised 7/2000) 

This form is the subpoena for witness appearance at a deposition. (Procedural Rule 18).
 
• Subpoena of Witness: (Revised 7/2000) 

This form is the subpoena for witness appearance and testimony at a hearing set before an Administrative Judge. (Procedural Rule 18).

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Previous format forms used by the Mississippi Workers' Compensation Commission.