Form B31 - Mississippi Workers' Compensation Commission - Notice Of Final Payment
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MWCC #
CARRIER FILE #
Mississippi Workers’ Compensation Commission
(2) SOCIAL SECURITY #
(3) DATE OF INJURY OR DEATH
NOTICE OF FINAL PAYMENT
PRINT OR TYPE
(1) EMPLOYEE NAME AND ADDRESS - (INCLUDE CITY, STATE and ZIP)
(4) DATE DISABILITY BEGAN
(5) DATE MAXIMUM MEDICAL
IMPROVEMENT
(6) DATE RETURNED TO WORK
(7) DATE OF FINAL PAYMENT
(8) EMPLOYER NAME AND ADDRESS - (INCLUDE CITY, STATE and ZIP)
(9) INSURANCE CARRIER NAME & SERVICING CO. (if applicable)
NOTICE: If salary paid in lieu of compensation, report below the amount
Compensation payments were made as follows:
of compensation which would have otherwise been due.
(10) Average Weekly Wage:
$_____________________
(11) Rate of Weekly Compensation $_________________
A. DISABILITY PAYMENTS
B. DEATH PAYMENTS
(12) _____ Weeks _____ Days Temporary Total
$
(16) _____ Weeks _____ Days (itemize at 26 below)
$
(13) _____ Weeks _____ Days Temporary Partial $
(17) $250 Payment to Spouse (Section 71-3-25(a))
$
(14) _____ Weeks _____ Days Permanent Partial $
(18) Funeral Expenses
$
_________% loss to __________________________
(19) Second Injury Fund
$
(15) _____ Weeks _____ Days Permanent Total
$
Total Disability Payments $
Total Death Payments
$
C. SETTLEMENT PAYMENTS
D. OTHER PAYMENTS
(20) Lump Sum
$
(23) Total Medical Expenses
$
(21) Compromise
$
(24) Rehabilitation Expenses
$
(22) Third Party: (Attach order if not approved by MWCC)
(25) Other (Specify)
$
a. Amt. reimbursed for comp. previously paid
(Subtract reimbursements) $ (
)
TOTAL PAYMENTS
b. Amt. credited against future liability
$
(A + B + C* + D)
$
Total Settlement Payments $
*If C is a negative amount, subtract from total)
(26) Dependents and Spouse Payments Itemized Below (attach separate page if necessary)
Name and Relationship
Rate
Weeks
Days
Total
a.
$
b.
$
c.
$
d.
$
(27) If full compensation was not paid, explain: (attach separate page if necessary)
NOTICE TO EMPLOYEE OR BENEFICIARY
This is NOT a release of the employer’s or the insurance carrier’s workers’ compensation liability. It is a statement of workers’ compensation
benefits already paid. If no further workers’ compensation benefits are provided within one (1) year from the date this form is properly filed with
the Commission, the right to any further such benefits may be barred by the applicable statute of limitations and this claim finally closed.
Exceptions may apply for incompetents or minors. If you incur additional loss of time from work, additional medical expense, or other additional
expense, due to this injury, you should immediately contact your employer, the insurance carrier, or the Mississippi Workers’ Compensation
Commission for further guidance.
PHONE #:
_______________________
___/___/___
Employee’s Signature:
Date
_______________________
___/___/___
Prepared by:
Date
(or representative or beneficiary)
MWCC Form B31 (10/03)
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