Free A-24 - Proof of Coverage: (Revised 3/99) Acrobat format, 3-up printable. - Mississippi


File Size: 3.4 kB
Pages: 1
File Format: PDF
State: Mississippi
Category: Workers Compensation
Word Count: 147 Words, 2,977 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.mwcc.state.ms.us/forms/a-24.pdf

Download A-24 - Proof of Coverage: (Revised 3/99) Acrobat format, 3-up printable. ( 3.4 kB)


Preview A-24 - Proof of Coverage: (Revised 3/99) Acrobat format, 3-up printable.
TO THE MISSISSIPPI WORKERS' COMPENSATION COMMISSION: Employer _____________________________________________________________________ Address ______________________________________________________________________ Locations Covered _____________________________________________________________ Nature of Business _____________________________________________________________ This is to certify that the Workers' Compensation policy of the employer described herein has been: Issued ___________________ Renewed __________________ Canceled _________________ Policy Number ______________________ Effective ______________ Expires _____________ Reason for cancellation __________________________________________________________ _____________________________________________________________________________ Compulsory risk _________________________ Exempted Risk _________________________ Carrier: ___________________________________ Issuing office ________________________

Revised 7/15/49 Form A-24

TO THE MISSISSIPPI WORKERS' COMPENSATION COMMISSION: Employer _____________________________________________________________________ Address ______________________________________________________________________ Locations Covered _____________________________________________________________ Nature of Business _____________________________________________________________ This is to certify that the Workers' Compensation policy of the employer described herein has been: Issued ___________________ Renewed __________________ Canceled _________________ Policy Number ______________________ Effective ______________ Expires _____________ Reason for cancellation __________________________________________________________ _____________________________________________________________________________ Compulsory risk _________________________ Exempted Risk _________________________ Carrier: ___________________________________ Issuing office ________________________
Revised 7/15/49 Form A-24

TO THE MISSISSIPPI WORKERS' COMPENSATION COMMISSION: Employer _____________________________________________________________________ Address ______________________________________________________________________ Locations Covered _____________________________________________________________ Nature of Business _____________________________________________________________ This is to certify that the Workers' Compensation policy of the employer described herein has been: Issued ___________________ Renewed __________________ Canceled _________________ Policy Number ______________________ Effective ______________ Expires _____________ Reason for cancellation __________________________________________________________ _____________________________________________________________________________ Compulsory risk _________________________ Exempted Risk _________________________ Carrier: ___________________________________ Issuing office ________________________
Revised 7/15/49 Form A-24