Form Mwcc A-16 - Notice Of Coverage - 1999 printable pdf download

Form Mwcc A-16 - Notice Of Coverage - 1999

NOTICE OF COVERAGE

MISSISSIPPI WORKERS’ COMPENSATION COMMISSION

P.O. BOX 5300

JACKSON, MISSISSIPPI 39296-5300

601-987-4200

As required by Code Section 71-3-81 (Section 35 of Act), notice is hereby given that the

undersigned employer has secured the payment of compensation under the provisions of the

Mississippi Workers’ Compensation Law.

The name and address of the Self-Insurer/Carrier is:

NAME: ________________________________________________________________

ADDRESS: _____________________________________________________________

The date of the expiration of the policy is: _______ day of _____________, year ______.

Notice is hereby given, in accordance with Code Section 71-3-35 (1) (Section 12 of Act), that

your employer has been designated to receive notices of injury, __________________________,

(Name of Employer Representative)

being the _______________________________ of the employer. In all cases of injury such

(Title of Employer Representative)

person should be notified immediately as provided by Code Section 71-3-35 (Section 12 of Act).

Dated and posted on the _________ day of _____________________, year __________.

_________________________________________

(Name of Employer)

By ______________________________________

(Signature of Authorized Representative)

This notice is required to be posted in a conspicuous place or places in or about the employer’s

place of business.

MISSISSIPPI WORKERS’ COMPENSATION COMMISSION

JACKSON, MISSISSIPPI

MWCC A-16 (Revised 5-99)

Form Mwcc A-16 - Notice Of Coverage - 1999