Employers Notice Of Controversion {B-52}

MISSISSIPPI WORKERS COMPENSATION COMMISSION Post Office Box 5300, Jackson, Mississippi 39296-5300 MWCC FILE EMPLOYERS NOTICE OF CONTROVERSION NUMBER CARRIER FILE NUMBER EMPLOYEE CLAIMANT SOC. SEC. NO. NATURE OF INJURY ADDRESS DATE OF BIRTH AGE SEX CITY STATE ZIP INJURY DATE EMPLOYER INSURANCE CARRIER _______________________________________________________________ _____________________________________________________________ _______________________________________________________________ _____________________________________________________________ ADDRESS ADDRESS _______________________________________________________________ _______________________________________________________________ CITY STATE ZIPCITY STATE ZIPPursuant to Section 71-3-37(4) of the Mississippi Workers Compensation Act, the above named employer controverts the referenced employees 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)