Workers' Compensation Standard Forms

Mississippi Workers' Compensation Commission
Standard Forms

WC Forms Available. Standard forms of the Mississippi Workers' Compensation Commission are now available in Omniform Format. Omniform format means you can complete and print the forms directly from your computer without having to use a typewriter.
How does this work? You obtain the Omniform Internet Reader free of charge by clicking here. You can then select forms and complete them on your computer and print the completed form.
Is there a fee involved? Yes. In order to pay for providing the forms in electronic format and to pay for the other Workers' Compensation information provided free, an annual fee of $25.00 is charged. Your Subscription allows you to use the forms for one year and then renew your subscription or cancel, return all forms and discontinue use. Note: If you have a subscription to MSLegalforms.com there is no addition charge for access to the WC forms. These subscribers can locate the forms at http://www.mslegalforms.com/
What do subscribers to WC Forms receive? Subscribers to WC Forms receive all current WC Forms in Omniform format and the free Omniform Reader program, as well as written instructions. Updates and revisions made during the year are included free of charge. You will receive the forms on floppy disk to install on your computer and also have full time access to all forms on-line.
How do I subscribe? Simply complete the Subscription Form and you will receive access on-line and all forms on floppy disk for loading onto your computer. You may also subscribe by calling LawNetCom, Inc. at (601) 825-0382.

Index of WC Forms Available
(Only subscribers may Access from these links)

"A" FORMS

A-16Notice of Coverage: (Revised 6-1-90) Every employer subject to the Mississippi Workers' Compensation Law is required to post this form in a conspicuous place in the place of business. (General Rule 8). Color Code - Manilla

A-24 Proof of Coverage: (Phased out begining January 1, 1993)

"B" FORMS

Standard IAIABC IA-1 Employer's First Report of Injury or Occupational Disease: (Adopted 10-1-96) 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 the injury or death. (Mississippi Code Annotated 71-3-67 (1972); Procedural Rule 1).

B-3 (First Report of Injury) Replaced by the IAIABC First Report

B-5, 11Petition to Controvert: (Revised 5-93) This form is the claimant's application for benefits and his request for a hearing. (Procedural Rule 2). Color Code - White

B-5, 22Answer: (Revised 10-96) This form is the response of the employer-carrier to the claimant's Petition to Controvert. (Procedural Rule 4). Color Code - White

B-9,27Preliminary Medical Report: (Revised 6-1-96) HCFA 1500 The attending physician completes this form for filing with the Commission within twenty (20) days following his first treatment and periodically thereafter. (Section Prelim / Progress) (Section Final Report) This form for filing with the Commission at the conclusion of the medical treatment. (Mississippi Code Annotated 71-3-15 (1972); General Rule 9).

B-15 (Notice of First Payment) Combined into B-18

B-16 (Suspension of Payment) Combined into B-18

B-17 (Supplemental Agreement) Combined into B-18

B-18(Payment Form) Combined B-15, B-16 and B-17 (Revised 7-1-96): See instructions on reverse side of this form.

B-19Application for Lump Sum Payment: (Revised 1-1-70) This form is filed by the claimant to request a lump sum payment in accordance with the provisions of Mississippi Code Annotated 71-3-37(10) (1972)). (General Rule 13; Procedural Rule 15).

B-27 (Final Medical Report) Combined into B-9,27

B-27-D (Dentist's Certification of Treatment and Report)(Discontinued 7-1-95).

B-31Report of Payment and Settlement Receipt: (Major Revision 10-1-96) Color Code - White Paper 10-29-96) This form is filed with the Commission within thirty (30) days following final payment of all benefits. (Mississippi Code Annotated 71-3-37(7) (1972); Procedural Rule 17).

B-39 (Quarterly Report of Medical Only Injuries) (Discontinued 7-1-95)

B-52 Employer's Notice of Controversion: (Instituted 9-1-93) The employer or carrier files this form in the event a claim is being denied. (Mississippi Code Annotated 71-3-37(4); Procedural Rule 2).

"C" FORMS

C-1Commission Notification: (Revised 4-1-89) Mailed to claimant upon filing of unsigned B-31 in noncontroverted case. (Procedural Rule 17).

"R" FORMS

R-1Early Notification of Severe Injury: (Instituted 7-1-82). This form is filed by employer-carrier immediately with the Commission to give notice of severe injuries. This is used in addition to the IAIABC IA-1(B-3). (Mississippi Code Annotated 71-3-105 (1972); Procedural Rule 19).

R-2Referral for Rehabilitation and Rehabilitation Initial Report: This form is used to refer candidates for rehabilitation to the Vocational Rehabilitation Division of the Mississippi Department of Education and to other rehabilitation suppliers. (Mississippi Code Annotated 71-3-105 (1972); Procedural Rule 19).

Subpoena Forms

Additional Instructions

Please use the MWCC number when filing all forms in connection with a claim reported to the Commission.

NOTE: All forms are now color code White except form A-16 which is color code manilla. If manilla is not available, then some color, other than white, should be used for easy and conspicuous identification.