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Proof Of Coverage Form. This is a Mississippi form and can be use in Workers Compensation.
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Tags: Proof Of Coverage, A-24, Mississippi Workers Compensation,
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
