Get Moclaim

Filling out the Moclaim form is a crucial step for individuals seeking compensation for injuries sustained in the workplace. This guide provides clear, step-by-step instructions on how to accurately complete the Moclaim form online, ensuring all necessary information is included for a successful submission.

Follow the steps to complete the Moclaim form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing the injured employee’s personal information in the designated fields, including their first name, middle initial, last name, mailing address, and social security number.
3. In Box 4, indicate the date of the accident or the onset of the occupational disease. Be sure to follow the guidelines for multiple dates provided in the instructions.
4. Complete Box 5 by entering the average weekly wage earned by the employee prior to the injury. Ensure the figure reflects gross wages.
5. In Box 7, include the place of the accident with all relevant details, including city, county, state, and ZIP code.
6. Describe the circumstances of the injury in the space provided in Box 9, detailing what the employee was doing when the injury occurred.
7. If applicable, list all employers against whom this claim is being filed in Box 10. If more than three employers are involved, please attach additional sheets with relevant information.
8. Complete Box 12 if filing a claim against the Second Injury Fund, checking the appropriate box(es) according to the nature of the claim.
9. If the injury resulted in death, fill out Box 14 and 15 with the necessary details about the deceased employee and their dependents.
10. Finally, ensure that the injured employee or claimant's signature is affixed in Box 16. If an attorney is representing the claimant, they should also sign in the appropriate section.
11. After completing the form, save your changes, and either download, print, or share the form as required. If submitting by mail, remember to include the original and necessary copies.

Complete your Moclaim online today for a smoother filing process.