Get Mississippi Workers Compensation Forms 2020-2025

Filling out the Mississippi Workers Compensation Forms online is essential for reporting workplace injuries or illnesses accurately. This guide will help you navigate through the components of the form, ensuring that you provide all required information clearly and correctly.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling out the employer's name and address, including the ZIP code. This information is crucial for identifying the organization involved in the claim.
3. Enter the carrier or administrator claim number. This ensures that your report is connected to the correct insurance policy.
4. Select the report purpose code from the provided options to indicate the reason for filing the report.
5. Fill in the jurisdiction claim number, which helps in tracking the claim for regulatory purposes.
6. Provide the employer's location address if it differs from the primary address. This may help in addressing any specific location-related concerns.
7. Input the Standard Industrial Classification (SIC) code, which categorizes the type of work performed.
8. Supply the employer's Federal Employer Identification Number (FEIN) as it relates to tax and employee identification.
9. Enter the details of the carrier or claims administrator, including their name, address, and phone number.
10. Indicate the policy period of the insurance coverage applicable to the claim.
11. If utilizing self-insurance, check the appropriate box and include the self-insured number and Federal Employer Identification Number of the administrator.
12. Complete the employee's details by filling out their full name, date of birth, social security number, address, occupation, and contact information.
13. Specify the employee's marital status, employment status, and number of dependents.
14. Report the date and time of the injury or illness occurrence, including additional details about the circumstances surrounding the event.
15. Describe the type of injury or illness, including the part of the body affected, and provide relevant codes where applicable.
16. List any witnesses to the incident, along with their contact phone numbers.
17. Review all information for accuracy and completeness, as inaccuracies can delay processing.
18. Once the form is completely filled out, you can save your changes, download, print, or share the form as required.

Complete your Mississippi Workers Compensation Forms online to ensure timely processing of your claim.