Mwcc Form B-18 - Notice Form - Mississippi Workers' Compensation Commission printable pdf download

Mwcc Form B-18 - Notice Form - Mississippi Workers' Compensation Commission

MISSISSIPPI WORKERS' COMPENSATION COMMISSION

MWCC File No.:

Injury Date

Carrier File No.:

Disability Date

Type of NOTICE:

NOTICE OF FIRST PAYMENT OF T.T.D. BENEFITS

SUPPLEMENTAL AGREEMENT AS TO COMPENSATION

NOTICE OF SUSPENSION OF PAYMENT

I. GENERAL INFORMATION

Employee Name and Address (Include City, State, and Zip)

Insurance Carrier Name and Address (Include City, State, and Zip)

SSN:

Birth Date

FEIN:

Employee Name and Address (Include City, State, and Zip)

Insurance Carrier Name and Address (Include City, State, and Zip)

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:

First Check Amount: $

Compensation Rate:$

III. SUPPLEMENTAL AGREEMENT: Please take notice that we agree, subject to applicable statutory limitations, to the

,and is now receiving benefits

: Employee again became temporarily totally disabled on

EMPORARY

OTAL

therefor at the rate of $

per week and continuing until further notice.

: Employee first became, or again became temporarily partially disabled

at the rate of 2/3

EMPORARY

ARTIAL

of the decrease in wage earning capacity and continuing until further notice.

: Employee is entitled to compensation for permanent total disability

, at the rate of

ERMANENT

OTAL

per week, and continuing for a period of

weeks.

commencing on

: Employee is entitled to compensation for the

ERMANENT

ARTIAL

at the rate of $

per week, and continuing for a period of

weeks.

at the combined rate of $

: Dependents are entitled to death benefits commencing on

EATH

per week. Said benefits will continue for the statutorily prescribed period. (Itemize below - attach additional page if necessary).

THER

Death: Name of Beneficiary and Address

Relation

Date of Birth

Weekly Rate

IV. NOTICE OF SUSPENSION OF PAYMENT:

paid on

Please take notice that the payment of compensation has been suspended, and was last

, at the rate of $

per week for the following

Temporary Total

Temporary Partial

Permanent Total

Permanent Partial

Death

Other

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)

Mwcc Form B-18 - Notice Form - Mississippi Workers' Compensation Commission

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