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To identify the contact person for your company, print the form below and send the completed form to CIS.

 

FORM MS-3

MISSISSIPPI WORKERS' COMPENSATION

 ASSIGNED RISK POOL

MEMBER COMPANY CONTACT FORM

 

The Governing Articles of the Mississippi Workersí Compensation Assigned Risk Pool provide that each Member shall designate and provide to the Pool Administrator the name and address of an official of the Memberís organization with authority to represent the Member in its dealings with the Pool and to whom all correspondence from the Pool shall be sent. Form MS-3 is used for this purpose.

You should file Form MS-3 if no contact person is listed on the cover page accompanying this form. You should also file Form MS-3 if the contact information on the cover page is incorrect or incomplete. If you have previously filed Form MS-3 and none of the contact information has changed, there is no need to file another Form MS-3. (Note - If you are a member of an affiliated group that has properly elected group reporting to the Mississippi Pool, only the reporting Member is required to complete and file Form MS-3.)

 

Return Form To:

Compensation Insurance Services

P.O. Box 12653

Jackson, MS 39236

Fax Number (601) 977-9466

 

 

 

Member Company Information

Company/Group Name:

Company Address:

City:

State:

Zip:

NCCI Carrier Number:

NAIC Number:

Mississippi License Number:

 

Contact Information

Contact Name:

Telephone #:

Title:

Fax #:

 

If contact personís address is different from Memberís address, please complete the following:

Company Name:

Company Address:

City:

State:

Zip:

Form MS-3 (Rev.2000.1)

 

 

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