Free Copy Request Form - Mississippi

Mississippi Workers' Compensation Commission
1428 Lakeland Drive / Post Office Box 5300 Jackson, Mississippi 39296-5300 (601) 987-4252 http://www.mwcc.state.ms.us
Liles Williams, Chairman Augustus L. Collins, Commissioner John R. Junkin, Commissioner

Phyllis Clark, Commission Secretary

______ REQUEST FOR COPIES ______REQUEST FOR FILE REVIEW DATE: RE: ____________________ TELEPHONE # _______________________ MWCC FILE NO.________________________________________ EMPLOYEE:____________________________________________ EMPLOYER:____________________________________________ TO: _________________________________________________________ Name of Individual or Firm making request _________________________________________________________ Address __________________________________________________________ City State Zip REPRESENTING: _______Claimant (Workers' Comp. Claim Only) _______ Employer/Carrier (Workers' Comp. Claim Only) _______ Other (for example: Civil Suit, Third Party, etc.) _________________________________________________________ TO BE COMPLETED BY COMMISSION PERSONNEL APPROVED FOR REVIEW/AND OR COPIES: _______ ENTIRE FILE _______ CLAIM FILE EXCLUDING MEDICAL
If copies are requested, there is a charge of $.10 per page for parties of record with a minimum charge of $5.00 which includes postage. A charge of $.50 per page to non-parties. (See Commission General Rule 15 as amended September 1, 1993.)

NUMBER OF COPIES REQUESTED:_________ AT $._______PER PAGE. TOTAL CHARGE: ______________
This amount is due upon receipt of copies. M AKE CHECKS PAYABLE TO M ISSISSIPPI W ORKERS' COM PENSATION COM M ISSION. TAX I. D. NO. 646000841