Form B-18 - Notice Of First Payment Of T.t.d. Benefits / Notice Of Suspension Of Payment - Mississippi Workers' Compensation Commission
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1
2MISSISSIPPI WORKERS' COMPENSATION COMMISSION
MWCC FILE NO. ______________________________________
Injury Date
_____/______/______
_____/______/______
Carrier File No.
______________________________________
Disability Date
Type of NOTICE: (Click to select)
____________ NOTICE OF FIRST PAYMENT OF T.T.D. BENEFITS
____________ SUPPLEMENTAL AGREEMENT AS TO COMPENSATION
____________ NOTICE OF SUSPENSION OF PAYMENT
I. GENERAL INFORMATION (Use Tab key to advance through fields)
Employee Name and Address (Include City, State, and Zip)
Insurance Carrier Name and Address (Include City, State, and Zip)
_______-______-_______
Birth Date_____/____/_____
_________________________
SSN:
FEIN:
Employer Name and Address (Include City, State, and Zip)
)
Claim Administrator Name and Address (Include City, State, and Zip
_________________________
FEIN:
: _________________________
FEIN
II. NOTICE OF FIRST PAYMENT
: Please take notice that payment of compensation for temporary total disability has begun and will continue until further notice:
_____/______/______
Date of First Check:
Average Weekly Wage:
$______________________
_____/______/______
_____/______/______
Period Paid From:
to
First Check Amount:
$____________________
Compensation Rate:
$______________________
III. SUPPLEMENTAL AGREEMENT: Please take notice that we agree, subject to applicable statutory limitations, to the following:
G
T
T
: Employee again became temporarily totally disabled on _____/______/______, and is now receiving benefits therefor at
EMPORARY
OTAL
the rate of $____________________ per week and continuing until further notice.
G
T
P
: Employee first became, or again became temporarily partially disabled on _____/______/______, and is now receiving
EMPORARY
ARTIAL
benefits therefor at the rate of 2/3 of the decrease in wage earning capacity and continuing until further notice.
G
P
T
: Employee is entitled to compensation for permanent total disability commencing on _____/______/______, at the rate of
ERMANENT
OTAL
$_________________ per week, and continuing for a period of ___________ weeks.
G
P
P
: Employee is entitled to compensation for the __________% loss of ____________________________, commencing on
ERMANENT
ARTIAL
_____/______/______, at the rate of $____________________ per week, and continuing for a period of __________ weeks.
G
D
: Dependents are entitled to death benefits commencing on _____/______/______, at the combined rate of $____________________ per
EATH
week. Said benefits will continue for the statutorily prescribed period. (Itemize below - attach additional page if necessary).
G
O
:_____________________________________________________________________________________________________________
THER
Death: Name of Beneficiary and Address
Relation
Date of Birth
Weekly Rate
a.
$
b.
$
c.
$
d.
$
:
IV. NOTICE OF SUSPENSION OF PAYMENT
Please take notice that the payment of compensation has been suspended, and was last paid on
_____/______/______, at the rate of $ _________________ per week for the following:
G T
G T
G P
G P
G D
GOTHER______________________
T
P
T
P
EMPORARY
OTAL
EMPORARY
ARTIAL
ERMANENT
OTAL
ERMANENT
ARTIAL
EATH
_________________________________________________________________________________.
Reason compensation was suspended:
Average weekly wage at time of injury was $
Employee returned to work at weekly wage of $___________________.
________________________.
I certify that a copy of this Form has been furnished to the above named employee, beneficiary, or representative on _____/______/______.
Name: ___________________________________________ Title: ______________________________________ Phone:________________________
MWCC Form B-18 (Revised 7-96)
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