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FORM MS-10 MISSISSIPPI WORKERS COMPENSATION ASSIGNED RISK POOL REPORT OF CALENDAR YEAR PREMIUM WRITTEN FOR CALENDAR YEAR Reporting Company: NAIL #: CCI #: MS LICENSE # Address: (1) WORKERS COMP DIRECT

How to fill out form ms-10 mississippi workers39

How to Fill Out Form MS-10 Mississippi Workers'?

1. Start by obtaining the form: The Mississippi Workers' Compensation Commission website is the official source for obtaining Form MS-10. You can download it from their website or request a physical copy by contacting the commission directly.
2. Provide your personal information: Begin by filling in your personal details, such as your full name, address, date of birth, and Social Security number. Ensure that this information is accurate and up-to-date.
3. Enter employer information: Include the name, address, and contact details of your employer or the company for which you were working at the time of the incident. Provide as much information as possible to help identify the employer accurately.
4. Specify injury details: In this section, provide a detailed description of the incident or injury that occurred. Include the date, time, and location of the event. Be specific about the nature of the injury, whether it was physical or mental, and explain how it happened.
5. Provide medical information: List all healthcare providers that have treated you for this injury, including doctors, hospitals, or clinics. Include the dates of treatments and any medical reports or documentation that support your claim.
6. Outline the wage information: Employers are required to provide wage details to accurately calculate compensation. Fill in the section that asks for your average weekly wage, as well as any overtime or additional income you were receiving at the time of the injury.
7. Sign and date the form: After completing all the required sections, sign and date the form. Ensure that your signature is legible and matches the name you provided earlier.

Who needs Form MS-10 Mississippi Workers'?

Employers or employees who have experienced work-related injuries in Mississippi may need to complete Form MS-10. This form is crucial in initiating the workers' compensation process and documenting the incident for potential claims. Employers are responsible for providing this form to their employees upon injury, and it must be filled out accurately and promptly to ensure timely processing of the claim.

It is important to note that the specific requirements for using Form MS-10 may vary depending on the nature of the injury, the employer, and the guidelines set forth by the Mississippi Workers' Compensation Commission. It is recommended to consult with legal professionals or the commission directly for any specific questions or concerns regarding the utilization of Form MS-10.

For pdfFiller’s FAQs

What is form ms-10 mississippi workers39?

Form MS-10 Mississippi Workers39 is a form used for reporting work-related injuries and illnesses in the state of Mississippi.

Who is required to file form ms-10 mississippi workers39?

Employers in Mississippi are required to file form MS-10 Mississippi Workers39 for any work-related injuries or illnesses that occur in their workplace.

How to fill out form ms-10 mississippi workers39?

To fill out form MS-10 Mississippi Workers39, employers need to provide information about the injured or ill worker, the nature of the injury or illness, and the circumstances surrounding the incident.

What is the purpose of form ms-10 mississippi workers39?

The purpose of form MS-10 Mississippi Workers39 is to track work-related injuries and illnesses in Mississippi in order to improve workplace safety and prevent future incidents.

What information must be reported on form ms-10 mississippi workers39?

Form MS-10 Mississippi Workers39 requires information such as the worker's name, date of birth, employer information, date and time of injury or illness, description of the incident, and any medical treatment received.

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