Application For Lump Sum Payment {B-19}

MISSISSIPPI 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 answ. ersPART I - FOR EMPLOYEE BENEFITS: (Complete Items 1 thru 10 and 14 thru 18) 4. Employees address _______________________________________________________________________ ________________________ (No. and Street) (City) (State) 5. Employees 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 w ______________________________ork? 10. Total amount of compensation received since being released to return to w ___________________________________________ork 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. Applicants 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 paym________________________________________________________________ent? 15. List name and date of birth of all members of your immediate fam ily _________________________________________________ ________________________________________________________________________ ________________________________________ 16. Do any of them have an independent income separate from y _______.ours? Amount: ___________________________________ 17. Do you have an income other than your compensation paym _______.ents? 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)