Form B-19 - Application For Lump Sum Payment - Mississippi Workers' Compensation Commission
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1MISSISSIPPI WORKERS' COMPENSATION COMMISSION
P. O. Box 5300
JACKSON, MISSISSIPPI 39296
____________________
MWCC File No.
APPLICATION FOR LUMP SUM PAYMENT
Miss. Code Ann. §71-3-37(10) (Rev. 2000)
1. Name of injured employee and SSN
:_____________________________________________________________________________
(First Name)
(Middle Initial)
(Last Name)
(SSN)
2. Date of Injury
___________________________
3. Employer: __
Carrier:____________________________________________
___________________________________________
NOTE: In answering the following questions, use separate sheet of paper or back of this form, if necessary, to give complete answers.
PART I - FOR EMPLOYEE BENEFITS: (Complete Items 1 thru 10 and 14 thru 18)
4. Employee's address
_______________________________________________________________________________________________
(No. and Street)
(City)
(State)
5. Employee's date of birth
6. Date Disability began
_______________________________
____________________________________
(Mo.)
(Day)
(Yr.)
7. Have you returned to work?
If so, give date
________
___________________________________________________________________
8. Have you been released by a physician as able to return to work?
If so, date?
________.
__________________________________
9. How many weeks' compensation have you received since being released to return to work?
______________________________
10. Total amount of compensation received since being released to return to work
___________________________________________
PART II - FOR DEATH BENEFITS: (Complete Items 1 thru 3 and 11 thru 18)
11. Name of applicant
__________________________________________________________________________________________________
(First Name)
(Middle Initial)
(Last Name)
12. Applicant's date of birth
___________________________________________________________________________________________
(Mo.)
(Day)
(Year)
13. Address of applicant
_____________________________________________________________________________________________
(No. and Street)
(City)
(State)
PART III - FOR ALL APPLICANTS:
14. For what purpose do you request a lump sum payment?
________________________________________________________________
15. List name and date of birth of all members of your immediate family
_________________________________________________
________________________________________________________________________________________________________________
16. Do any of them have an independent income separate from yours?
Amount:
_______.
___________________________________
17. Do you have an income other than your compensation payments?
Amount
_______.
: ___________________________________
18. If request is other than Full Lump Sum Payment, state amount requested
________________________________________________
______________________________
_____________________________________________________
Date
Signature of Employee/Applicant and Phone Number
STATE OF ______________________
COUNTY OF _____________________
SUBSCRIBED AND SWORN TO before me this the _________ day of _____________________________, 20_____.
___________________________________________
Notary Public
____________________________________________________________
Signature and MS Bar Number of Attorney for Employee/Applicant
MWCC Form B-19 (Revised 1/2003)
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