MISSISSIPPI WORKERS COMPENSATION NOTICE OF COVERAGE

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MISSISSIPPI WORKERS’ COMPENSATION

NOTICE OF COVERAGE

I. Please take notice that your Employer is in compliance with the requirements of the Mississippi Workers’ Compensation Law, and [select one] [has been approved by the Mississippi Workers’

Compensation Commission to act as a self-insurer], or [maintains workers’ compensation insurance coverage with the following:]

(Name of insurance carrier or self-insurance group)

(address & telephone number)

II. Individual workers’ compensation claims will be submitted to and processed by:

(Name of third party claims administration or claims office)

(address & phone number)

III. This workers’ compensation coverage is effective for the following period:

____________ to ______________.

IV. All job related injuries or illnesses should be reported as soon as possible to your immediate supervisor, or to the person listed below:

(Name of employer contact person)

(Title & Department/Division)

V. Please be advised that any person who willfully makes any false or misleading statement or representation for the purpose of obtaining or wrongfully withholding any benefit or payment under the Mississippi Workers’ Compensation Law may be charged with violation of Miss.

Code Ann. §71-3-69 (Rev. 2000) and upon conviction be subjected to the penalties therein provided.

2001 M.W.C.C. Notice of Coverage Form

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COMPENSACIÓN AL TRABAJADOR DE MISSISSIPPI

NOTIFICACIÓN DE COBERTURA

I. Por favor tome nota que su Empleador está en cumplimiento con los requisitos de la Ley de Compensación al Trabajador de Mississippi, y [seleccione uno] [ha sido aprobado por la Comisión de Compensación al Trabajador de Mississippi para actuar como asegurador de sí mismo], o [mantiene seguro de compensación al trabajador con el siguiente:]

(Nombre del asegurador o grupo de seguro propio)

(dirección y número de teléfono)

II. Los reclamos individuales de compensación al trabajador serán entregados y procesados por:

(Nombre del administrador de reclamos de terceros u oficina de reclamos)

(dirección y número de teléfono)

III. TEsta cobertura de compensación al trabajador está en vigencia durante el siguiente periodo:

____________ hasta ______________.

IV. Todas las lesiones o enfermedades laborales deben ser reportadas tan pronto como sea factible a su supervisor inmediato, o a la siguiente persona:

(Nombre de la persona de contacto del empleador)

(Título y departamento o división)

V. Por favor tenga presente que cualquier persona que intencionalmente hace cualquier declaración o representación falsa o engañosa con el propósito de obtener o retener erróneamente cualquier beneficio o pago bajo la Ley de Compensación al Trabajador de Mississippi puede ser acusado de infracción de Miss. Code Ann. §71-3-69 (Rev. 2000) y al ser condenado será sujeto a las penas provistas en ella.

2001 M.W.C.C. Formulario de Notificación de Cobertura

Print Date: 10/07

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Unemployment Insurance For Employees

I M P O R T A N T

This employer is registered with the Mississippi Department of Employment Security, and the employees are covered by Unemployment Insurance. This insurance is carried to protect

you in case of unemployment through no fault of your own.

Nothing is deducted from your pay to cover its cost.

If you become unemployed, report to the nearest Mississippi Department of Employment Security WIN Job Center for work search assistance.

You may file a claim for Unemployment Insurance benefits online at mdes.ms.gov or by phone

at 888-844-3577.

Employer: Please Post in a Conspicuous Place Extra Copies on Request

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An equal opportunity employer and program, MDES has auxiliary aids and services available upon request to those with disabilities.

Those needing TTY assistance may call 800-582-2233.

Funded by the U.S. Department of Labor through the Mississippi Department of Employment Security, a proud member of America’s Workforce Network

MDES Communications 0511

Print Date: 6/11

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Seguro de Desempleo para Empleados

I M P O R T A N T E

Este patrono esta registrado con el Departamento de Seguro de

Empleo de Mississippi, y los empleados están cubiertos por el Seguro de Desempleo. Este seguro es llevado acabo para protegerlo en caso de que usted sea desempleado sin ninguna culpa de su parte.

Nada es deducido de su pago para cubrir su costo.

Si usted llegase a ser desempleado, repórtelo al Centro de Trabajo WIN del Departamento de Seguro de Desempleo de Mississippi más cercano para asistencia de búsqueda de trabajo.

Usted puede someter una reclamación para beneficios de Seguro de Desempleo por el Internet visitando la página web -mdes.ms.gov ó por teléfono llamando al 888-844-3577.

Patrono: Favor de Poner en un Lugar Llamativo Copias Adicionales si se Solicitan

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Un programa y patrono con igualdad de oportunidad, Para personas con incapacidades, MDES tiene ayudas y servicios auxiliares disponibles cuando se solicitan.

Personas necesitando asistencia de TTY pueden llamar al 800-582-2233.

Fondos Auspiciados por el Departamento Laboral de EEUU a través del Departamento de Seguro de Empleo de Mississippi, un miembro orgulloso de la Red de la Fuerza Laboral de America.

MDES Communications 0511

Print Date: 6/11

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EQUAL OPPORTUNITY IS THE LAW

It is against the law for this recipient of Federal financial assistance to discriminate on the following bases:

Against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and

Against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1998 (WIA), on the basis of the beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA Title I—financially assisted programs or activity.

The recipient must not discriminate in any of the following areas:

Deciding who will be admitted, or have access, to any WIA Title I—financially assisted program or activity.

Providing opportunities in, or treating any person with regard to, such a program or activity; or

Making employment decisions in the administration of, or in connection with, such a program or activity.

What To Do If You Believe You Have Experienced Discrimination

If you think that you have been subjected to discrimination under a WIA Title I-financially assisted program or Activity, you may file a complaint within 180 days from the date of the alleged violation with either:

If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center:

The Director Civil Rights Center (CRC) U.S. Department of Labor

200 Constitution Avenue, NW, Room N-4123 Washington, D.C. 20210

Voice: (202) 693-6502-TTY: (202) 693-6516

If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient).

If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action.

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Equal Opportunity Employer Program

Auxiliary aids and services available upon request to individuals with disabilities.

State - Workforce Investment Act Equal Opportunity Officer Dovie Reed • Phone: 601-321-6024 • Email: dreed@mdes.ms.gov

Assistant Equal Opportunity Officer

Randy Langley • Phone: 601-321-6504 • Email: rlangley@mdes.ms.gov Equal Opportunity Compliance Coordinator

Stefanie W. Brown • Phone: 601-321-6031 • Email: sbrown@mdes.ms.gov Mississippi Department of Employment Security

P.O. Box 1699 • Jackson, Mississippi 39215-1699 • Fax: 601-321-6037 • TDD: 800-582-2233

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IGUALDAD DE OPORTUNIDAD ES LA LEY

Es contra la ley que si el destinatario de asistencia financiera federal la discrimine por las siguientes razones:

En contra de cualquier individuo en los Estados Unidos por razón de, raza, color, religión, sexo, edad, incapacidad, origen nacional, afiliación politica o credo; y

Encontra de cualquier beneficiario de programas asistidos financieramente bajo el Titulo l de “Workforce Investment Act” del 1998 (WIA), por razon del estatus de ciudadania siendo un inmigrante legalmente autorizado para trabajar en los Estados Unidos o de su participación en cualquiera de las programas o activitdades financieramente asistidos por WIA Titulo I.

Si el destinatario no discriminará en ninguna de las sieguietes’ areas:

Decidiendo quien será admitido o tendrá acceso a cualquiera de las programas o actividades de WIA assistidos financieramente por el Titulo I;

Proveyendo opportunidades en o el tratamiento de cualquier persona con relación a semejante programa o actividad; o en la toma de decisiones de empleo en la administracion de o en conección con semejante programa o actividad.

QUE HACER SI USTED CREE QUE HA EXPERIMENTADO DISCRIMINACIÓN?

Si usted cree que ha estado sujeto a discriminación bajo cualquiera de los programas o actividades de WIA asistidos financieramente por el Titulo I, usted puede presentar una querella dentro de los primeros 180 dias después de la alegada violacíon al Oficial de Op- portunidad de Igualdad (Equal Opportunity Officer) del estinatario (o la persona designada por el destinatario para este propósito); o

Si usted presenta un querella al destinatario, deberá esperar hasta que el destinatario expida una Notificación de Acción Final por escrito o hasta que pasen 90 días (lo primero que suceda), antes de presentar la querella al Centro de Drechos Civiles (Civil Rights Cen- ter) (vea la dirección arriba).

Director del Centro de Derechos Civiles (Civil Rights Center - CRC)

U.S. Department of Labor

200 Constitution Avenue, NW, Room N-4123 Washington, D.C. 20210

Voice: (202) 693-6502-TDD: (202) 693-6515

Si el destinatario no le provee una Notificacíon de Acción Final por escrito dentro de 90 dias de la fecha cuando usted presentó su querella, usted no tiene que esperar que el destinatario expida la notificación antes de presentar su querella al CRC. Sin embargo, de- berá presentar su querella dentro de 30 dias después del limite de 90 dias (en otras palabras, 120 dias después de haber presentado la querella al destinatario).

Si el destinatario le expide una Notificación Acción Final por escrito respondiendo a su querella pero usted no está satisfecho con la decisión o resolución, usted puede presentar su querella a CRC. Su querella deberá ser presentada al CRC dentro de 30 dias de la fecha en que usted reciba su Notificación de Acción Final.

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Programa de oportunidades de igualdad del empleo

Ayundantes auxiliares y servicios est’an disponibles para individuos con incapacidades si asi lo requieren.

State - Workforce Investment Act Equal Opportunity Officer Dovie Reed • Phone: 601-321-6024 • Email: dreed@mdes.ms.gov

Assistant Equal Opportunity Officer

Randy Langley • Phone: 601-321-6504 • Email: rlangley@mdes.ms.gov Equal Opportunity Compliance Coordinator

Stefanie W. Brown • Phone: 601-321-6031 • Email: sbrown@mdes.ms.gov Mississippi Department of Employment Security

P.O. Box 1699 • Jackson, Mississippi 39215-1699 • Fax: 601-321-6037 • TDD: 800-582-2233

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This Organization

Participates in E-Verify

This employer will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee’s Form I-9 to confirm work authorization.

IMPORTANT: If the Government cannot confirm that you are authorized to work, this employer is required to provide you written instructions and an opportunity to contact DHS and/or SSA before taking adverse action against you, including terminating your employment.

Employers may not use E-Verify to prescreen job applicants and may not limit or influence the choice of documents presented for use on the Form I-9.

In order to determine whether Form I-9 documentation is valid, this employer uses E-Verify’s photo matching tool to match the photograph appearing on some permanent resident and employment authorization cards with the official U.S. Citizenship and Immigration Services’ (USCIS)

photograph.

If you believe that your employer has violated its responsibilities under this program or has discriminated against you during the verification process based upon your national origin or citizenship status, please call the Office of Special Counsel at 800-255-7688, 800-237-2515 (TDD) or at www.justice.gov/crt/osc.

N O T I C E :

Federal law requires all employers to verify the identity and

employment eligibility of all persons hired to work

in the United States.

For more information on E-Verify, please contact DHS at:

888-897-7781

Employment Verification. Done.

Print Date: 2/12

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The E-Verify logo and mark are registered trademarks of Department of Homeland Security. Commercial sale of this poster is strictly prohibited. M-780 (rev. 12/2010)

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Este Empleador

Participa en E-Verify

Este empleador le proporcionará a la Administración del Seguro Social (SSA), y si es necesario, al Departamento de Seguridad Nacional (DHS), información obtenida del Formulario I-9 corre- spondiente a cada empleado recién con-

tratado con el propósito de confirmar la autorización de trabajo.

IMPORTANTE: En dado caso que el gob- ierno no pueda confirmar si está usted autorizado para trabajar, este empleador está obligado a proporcionarle las instrucciones por escrito y darle la oportunidad a que se ponga en contacto con la oficina del SSA y, o el DHS antes de tomar una determinación adversa en contra suya, inclusive despedirlo.

Los empleadores no pueden utilizar E-Verify con el propósito de re- alizar una preselección de aspirantes a empleo o para hacer nuevas verificaciones de los empleados actuales, y no deben restringir o

influenciar la selección de los documentos que sean presentados para ser utilizados en el Formulario I-9.

A fin de poder determinar si la docu- mentación del Formulario I-9 es valida o no, este empleador utiliza la herramienta de se- lección fotográfica de E-Verify para com- parar la fotografía que aparece en algunas de las tarjetas de residente y autorizaciones de empleo, con las fotografías oficiales del Servicio de Inmigración y Ciudadanía de los Estados Unidos (USCIS).

Si usted cree que su empleador ha violado sus responsabilidades bajo este programa, o ha discriminado en contra suya durante el proceso de verificación debido a su lugar de origen o condición de ciudadanía, favor ponerse en contacto con la Oficina de Asesoría Especial llamando al 1-800-255-7688 (TDD: 1-800-237-2515).

A V I S O :

La Ley Federal le exige a todos los empleadores que verifiquen la identidad y

elegibilidad de empleo de toda persona contratada

para trabajar en los Estados Unidos.

Para mayor información sobre E-Verify, favor ponerse en contacto con la oficina del DHS llamando al:

1-888-464-4218

Employment Verification. Done.

Print Date: 2/12

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The E-Verify logo and mark are registered trademarks of Department of Homeland Security. Commercial sale of this poster is strictly prohibited. M-780 (rev. 12/2010)

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IF YOU HAVE THE RIGHT TO WORK, Don’t let anyone take it away.

If you have a legal right to work in the United States, there are laws to protect you against discrimination in the workplace.

You should know that –

No employer can deny you a job or fire you because of your national origin or citizenship status.

In most cases employers cannot require you to be a U.S. citizen or permanent resident or refuse any legally acceptable documents.

If any of these things have happened to you, you may have a valid charge of discrimination that can be filed with the OSC. Contact the OSC for assistance in your own language.

Call 1-800-255-7688. TDD for the hearing impaired is 1-800-237-2515.

In the Washington, D.C., area, please call 202-616-5594, TDD 202-616-5525 Or write to:

U.S. Department of Justice Office of Special Counsel -NYA 950 Pennsylvania Ave., N.W.

Washington, DC 20530

U.S. Department of Justice Civil Rights Division Office of Special Counsel for Immigration-Related Unfair Employment Practices

Print Date: 2/12

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SI USTED TIENE DERECHO A TRABAJAR, no deje que nadie se lo quite.

Si tiene derecho a trabajar legalmente en los Estados Unidos, existen leyes para protegerlo contra la discriminación en el trabajo.

Debe saber que –

Ningún patrón puede negarle trabajo, ni puede despedirlo, debido a su país de origen o su condición de inmigrante.

En la mayoría de los casos, los patrones no pueden exigir que usted sea ciudadano de los Estados Unidos o residente permanente o negarse a aceptar documentos validos por ley.

Si se ha encontrado en cualquiera de estas situaciones, usted podría tener una queja valida de discriminación.

Comuníquese con la Oficina del Consejero Especial (OSC) de Practicas Injustas en el Empleo Relacionadas a la Condición de Inmigrante para obtener ayuda en español.

Llame al 1-800-255-7688; TDD para personas con problemas de audición: 1-800-237-2515.

En Washington, DC, llame al (202) 616-5594: TDD para personas con problemas de audición: (202) 616-5525. O escríbale a OSC a la siguiente dirección:

U.S. Department of Justice Office of Special Counsel - NYA 950 Pennsylvania Ave., N.W.

Washington, DC 20530

Departamento de Justicia de los Estados Unidos, División de Derechos Civiles

Oficina del Consejero Especial

Print Date: 2/12

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Mississippi Workers’ Compensation Commission

1428 Lakeland Drive / Post Office Box 5300 Jackson, Mississippi 39296-5300

(601) 987-4200 http://www.mwcc.state.ms.us

Liles Williams, Chairman John R. Junkin, Commissioner

Debra H. Gibbs, Commissioner Ray C. Minor, Executive Director

NOTICE CONCERNING CHANGES TO THE WORKERS’

COMPENSATION LAW, EFFECTIVE JULY 1, 2012

Pursuant to Senate Bill 2576, which was passed during the 2012 Regular Session of the Mississippi Legislature, the Mississippi Workers’ Compensation Commission is required to promulgate a written statement specifying the changes being made to the Workers' Compensation Law by this Bill. This statement is to be made available to every employer in this State subject to the Workers' Compensation Law. This written statement is available at the Com- mission’s website: http://www.mwcc.state.ms.us/ , and the Commission will attempt to reach as many employers as possible by mailing written copies of this statement.

As provided in Senate Bill 2576, within ten (10) days of receipt of this written statement from the Commis- sion, “every employer shall post the Commission's statement in a conspicuous place or places in and about his place or places of business and adjacent to the Notice of Coverage as required by Section 71-3-81.” These changes shall take effect and be in force from and after July 1, 2012, and shall apply to injuries occurring on or after July 1, 2012.

A copy of this statement is being mailed to all known employers and/or their insurers. All insurers and third party administrators are asked to please notify their insureds of these requirements immediately upon re- ceipt of this statement.

The following is a summary of the changes made to the Workers’ Compensation Law by Senate Bill 2576. The changes themselves are underlined for easy reference.

-Section 71-3-1 is amended as follows in relevant part:

(1)…[T]his chapter shall be fairly and impartially construed and applied according to the law and the evidence in the record, and, notwith- standing any common law or case law to the contrary, this chapter shall not be presumed to favor one party over another and shall not be liberally construed in order to fulfill any beneficent purposes.

(3) The primary purposes of the Workers' Compensation Law are to pay timely temporary and permanent disability benefits to every worker who legitimately suffers a work-related injury or occupational disease arising out of and in the course of his employment, to pay reasonable and necessary medical expenses resulting from the work-related injury or occupational disease, and to encourage the return to work of the worker.

(1)… In all claims in which no benefits, including disability, death and medical benefits, have been paid, the claimant shall file medical records in support of his claim for benefits when filing a petition to controvert. If the claimant is unable to file the medical records in support of his claim for benefits at the time of filing the petition to controvert because of a limitation of time established by Section 71- 3-35 or Section 71-3-53, the claimant shall file medical records in support of his claim within sixty (60) days after filing the petition to controvert.

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(2) Where a preexisting physical handicap, disease, or lesion is shown by medical findings to be a material contributing factor in the results following injury, the compensation which, but for this subsection, would be payable shall be reduced by that proportion which such preexisting physical handicap, disease, or lesion contributed to the production of the results following the injury. The preexisting condi- tion does not have to be occupationally disabling for this apportionment to apply.

(4) No compensation shall be payable if the use of drugs illegally, or the use of a valid prescription medication(s) taken contrary to the prescriber's instructions and/or contrary to label warnings, or intoxication due to the use of alcohol of the employee was the proximate cause of the injury, or if it was the willful intention of the employee to injure or kill himself or another.

(1) …A physician to whom the employee is referred by his employer shall not constitute the employee's selection, unless the employee, in writing, accepts the employer's referral as his own selection. However, if the employee is treated for his alleged work-related injury or occupational disease by a physician for six (6) months or longer, or if the employee has surgery for the alleged work-related injury or occupational disease performed by a physician, then that physician shall be deemed the employee's selection.

(c)(24) Disfigurement: The commission, in its discretion, is authorized to award proper and equitable compensation for serious facial or head disfigurements not to exceed Five Thousand Dollars ($5,000.00). No such award shall be made until a lapse of one (1) year from the date of the injury resulting in such disfigurement.

-Section 71-3-19 is amended as follows:

An employee who as a result of injury is or may be expected to be totally or partially incapacitated for a remunerative occupation and who, under the direction of the commission is being rendered fit to engage in a remunerative occupation may, in the discretion of the commission under regulations adopted by it, receive additional compensation necessary for his maintenance, but such additional compensation shall not exceed Twenty-five Dollars ($25.00) a week for not more than fifty-two (52) weeks.

If the injury causes death, the compensation shall be known as a death benefit and shall be payable in the amount and to or for the benefit of the following persons:

(a) An immediate lump-sum payment of One Thousand Dollars ($1,000.00) to the surviving spouse, in addition to other compensation benefits.

(b) Reasonable funeral expenses not exceeding Five Thousand Dollars ($5,000.00) exclusive of other burial insurance or benefits.

(3)… Attorneys may not recover attorney's fees based upon benefits voluntarily paid to an injured employee for temporary or permanent disability. Any settlement negotiated by an attorney shall not be considered a voluntary payment.

-Section 71-3-121 is amended as follows:

(1) In the event that an employee sustains an injury at work or asserts a work-related injury, the employer shall have the right to administer drug and alcohol testing or require that the employee submit himself to drug and alcohol testing. If the employee has a positive test indicating the presence, at the time of injury, of any drug illegally used or the use of a valid prescription medication(s) taken contrary to the prescriber's instructions and/or contrary to label warnings, or eight one-hundredths percent (.08%) or more by weight volume of alcohol in the person's blood, it shall be presumed that the proximate cause of the injury was the use of a drug illegally, or the use of a valid prescription medication(s) taken contrary to the prescriber's instructions and/or contrary to label warnings, or the intoxication due to the use of alcohol by the employee. If the employee refuses to submit himself to drug and alcohol testing immediately after the alleged work- related injury, then it shall be presumed that the employee was using a drug illegally, or was using a valid prescription medication(s) contrary to the prescriber's instructions and/or contrary to label warnings, or was intoxicated due to the use of alcohol at the time of the accident and that the proximate cause of the injury was the use of a drug illegally, or the use of a valid prescription medication(s) taken contrary to the prescriber's instructions and/or contrary to label warnings, or the intoxication due to the use of alcohol of the employee.

The burden of proof will then be placed upon the employee to prove that the use of drugs illegally, or the use of a valid prescription medication(s) taken contrary to the prescriber's instructions and/or contrary to label warnings, or intoxication due to the use of alcohol was not a contributing cause of the accident in order to defeat the defense of the employer provided under Section 71-3-7.

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(2) The results of the drug and alcohol tests, employer-administered or otherwise, shall be considered admissible evidence solely on the issue of causation in the determination of the use of drugs illegally, or the use of a valid prescription medication(s) taken contrary to the prescriber's instructions and/or contrary to label warnings, or the intoxication due to the use of alcohol of an employee at the time of injury for workers' compensation purposes under Section 71-3-7.

(3) No cause of action for defamation of character, libel, slander or damage to reputation arises in favor of any person against an employer under the provisions of this section.

(d) An employer may administer drug and alcohol testing or require that the employee submit himself to drug and alcohol testing as provided under Section 71-3-121 in the event that the employee sustains an injury at work or asserts a work-related injury.

-A new section is created which states the following:

-The Workers' Compensation Commission shall promulgate a written statement specifying the changes made to the Workers' Compen- sation Law by this act to every employer in this state subject to the Workers' Compensation Law. Within ten (10) days of receipt of this written statement from the Commission, every employer shall post the Commission's statement in a conspicuous place or places in and about his place or places of business and adjacent to the Notice of Coverage as required by Section 71-3-81.

-This act shall take effect and be in force from and after July 1, 2012, and shall apply to injuries occurring on or after July 1, 2012.

MWCC June 14, 2012

EMPLOYERS

Upon receipt of this summary, post in a conspicuous place or places in and about your places of business and adjacent to the Notice of Coverage as required by Section 71-3-81.

INSURERS

Upon receipt of this summary, immediately provide a copy to each of your Mississippi insureds so that the posting requirements for employers can be timely satisfied.

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