Free B-52 - Employer's Notice of Controversion: (Instituted 9/93) - Mississippi

MISSISSIPPI WORKERS' COMPENSATION COMMISSION
Post Office Box 5300, Jackson, Mississippi 39296-5300 EMPLOYER'S NOTICE OF CONTROVERSION
MWCC FILE NUMBER CARRIER FILE NUMBER EMPLOYEE CLAIMANT ADDRESS CITY STATE ZIP SOC. SEC. NO. DATE OF BIRTH INJURY DATE AGE SEX NATURE OF INJURY

EMPLOYER _______________________________________________________________

INSURANCE CARRIER _____________________________________________________________

_______________________________________________________________ ADDRESS

_____________________________________________________________ ADDRESS

_______________________________________________________________ CITY STATE ZIP

_______________________________________________________________ CITY STATE ZIP

Pursuant to Section 71-3-37(4) of the Mississippi Workers' Compensation Act, the above named employer controverts the referenced employee's right to workers' compensation upon the following grounds:

I hereby certify that a copy of this notice has been served, by mail or personal delivery, to the above named employee at the most current address which can be determined by diligent inquiry or to his or her attorney, if represented. Dated: ___________________________ _______________________________________________
Signature of Employer/Carrier Representative _____________________________________________________ Title _____________________________________________________ Address _____________________________________________________ City State Zip Telephone number: MWCC Form B-52 (1993) ____________________________