Free B-19 - Application For Lump Sum Payment: (Revised 1/03) - Mississippi

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 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? 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)

__________________________________ ______________________________

9. How many weeks' compensation have you received since being released to return to work?

___________________________________________

12. Applicant's date of birth 13. Address of applicant

___________________________________________________________________________________________
(Mo.) (Day) (Year)

_____________________________________________________________________________________________
(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? _______. 18. If request is other than Full Lump Sum Payment, state amount requested Amount: ___________________________________
________________________________________________

______________________________
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)