Free B-31 - Report of Payment and Settlement Receipt: (Revised 10/03) - Mississippi

Mississippi Workers' Compensation Commission
GENERAL INFORMATION

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MWCC #

CARRIER FILE #

NOTICE OF FINAL PAYMENT
PRINT OR TYPE
(1) EMPLOYEE NAME AND ADDRESS - (INCLUDE CITY, STATE and ZIP)

(2) SOCIAL SECURITY #

(3) DATE OF INJURY OR DEATH

(4) DATE DISABILITY BEGAN

(5) DATE MAXIMUM MEDICAL IMPROVEMENT

(6) DATE RETURNED TO WORK

(7) DATE OF FINAL PAYMENT

(8) EMPLOYER NAME AND ADDRESS - (INCLUDE CITY, STATE and ZIP)

(9) INSURANCE CARRIER NAME & SERVICING CO. (if applicable)

Compensation payments were made as follows:
(10) Average Weekly Wage: A. DISABILITY PAYMENTS
(12) _____ Weeks _____ Days Temporary Total $ (13) _____ Weeks _____ Days Temporary Partial $ (14) _____ Weeks _____ Days Permanent Partial $ _________% loss to __________________________

NOTICE: If salary paid in lieu of compensation, report below the amount of compensation which would have otherwise been due.

$_____________________

(11) Rate of Weekly Compensation $_________________ B. DEATH PAYMENTS
(16) _____ Weeks _____ Days (itemize at 26 below) (17) $250 Payment to Spouse (Section 71-3-25(a)) (18) Funeral Expenses (19) Second Injury Fund $ $ $ $

COMPENSATION PAYMENTS

(15) _____ Weeks _____ Days Permanent Total

$

Total Disability Payments $ C. SETTLEMENT PAYMENTS
(20) Lump Sum (21) Compromise $ $

Total Death Payments D. OTHER PAYMENTS
(23) Total Medical Expenses (24) Rehabilitation Expenses (25) Other (Specify) ) TOTAL PAYMENTS

$
$ $ $

(22) Third Party: (Attach order if not approved by MWCC) a. Amt. reimbursed for comp. previously paid (Subtract reimbursements) $ ( b. Amt. credited against future liability $

(A + B + C* + D)
*If C is a negative amount, subtract from total)

Total Settlement Payments $
Name and Relationship a. b. c. d.

$

(26) Dependents and Spouse Payments Itemized Below (attach separate page if necessary) Rate Weeks Days $ $ $ $ Total

(27) If full compensation was not paid, explain: (attach separate page if necessary)

NOTICE TO EMPLOYEE OR BENEFICIARY
This is NOT a release of the employer's or the insurance carrier's workers' compensation liability. It is a statement of workers' compensation benefits already paid. If no further workers' compensation benefits are provided within one (1) year from the date this form is properly filed with the Commission, the right to any further such benefits may be barred by the applicable statute of limitations and this claim finally closed. Exceptions may apply for incompetents or minors. If you incur additional loss of time from work, additional medical expense, or other additional expense, due to this injury, you should immediately contact your employer, the insurance carrier, or the Mississippi Workers' Compensation Commission for further guidance.

NOTICE

PHONE #:
Prepared by:

_______________________Date

___/___/___

Employee's Signature:

_______________________ Date ___/___/___
(or representative or beneficiary)

MWCC Form B31 (10/03)