Employer'S Notice Of Controversion - Mississippi Workers' Compensation Commission
Download a blank fillable Employer'S Notice Of Controversion - Mississippi Workers' Compensation Commission in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Employer'S Notice Of Controversion - Mississippi Workers' Compensation Commission with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1MISSISSIPPI WORKERS' COMPENSATION COMMISSION
Post Office Box 5300, Jackson, Mississippi 39296-5300
MWCC FILE
EMPLOYER'S NOTICE OF CONTROVERSION
NUMBER
CARRIER FILE
NUMBER
EMPLOYEE CLAIMANT
SOC. SEC. NO.
NATURE OF INJURY
ADDRESS
DATE OF BIRTH
AGE
SEX
CITY
STATE
ZIP
INJURY DATE
EMPLOYER
INSURANCE CARRIER
_______________________________________________________________
_____________________________________________________________
_______________________________________________________________
_____________________________________________________________
ADDRESS
ADDRESS
_______________________________________________________________
_______________________________________________________________
CITY
STATE
ZIP
CITY
STATE
ZIP
Pursuant to Section 71-3-37(4) of the Mississippi Workers' Compensation Act, the above named employer
controverts the referenced employee's right to workers' compensation upon the following grounds:
I hereby certify that a copy of this notice has been served, by mail or personal delivery, to the above named
employee at the most current address which can be determined by diligent inquiry or to his or her attorney, if
represented.
Dated: ___________________________
_______________________________________________
Signature of Employer/Carrier Representative
_____________________________________________________
Title
_____________________________________________________
Address
_____________________________________________________
City
State
Zip
Telephone number:
____________________________
MWCC Form B-52 (1993)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal