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