Get Missouri Department Of Labor And Industrial Relations Division Of Workers Compensation Instructions

Filling out the Missouri Department of Labor and Industrial Relations Division of Workers Compensation Claim for Compensation form is an essential step for individuals seeking workers' compensation benefits after an injury or occupational disease. This guide provides a detailed overview of the form and offers clear, step-by-step instructions to ensure you complete the process accurately and efficiently.

Follow the steps to successfully complete the Claim for Compensation form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the employee information. Include the injured employee’s name, mailing address, social security number (last four digits), date of birth, and date of accident or occupational disease in the required fields.
3. In Box 5, ensure you provide the average weekly wage, as this is critical for compensation calculations.
4. Complete Box 7 with the ZIP Code where the accident occurred to help verify the location of the incident.
5. If applicable, check the appropriate box in Box 8 for claims related to occupational diseases due to toxic exposure.
6. In Box 12, indicate if the claim is being filed against the Second Injury Fund for permanent total disability benefits.
7. Fill out dependent information in Box 14 only if applicable. This includes names and dates of birth for any dependents if the employee has died.
8. Ensure that either the injured employee or their representative signs in Box 15. If an attorney represents the claimant, their information must also be completed.
9. Review the form for completeness and legibility. Make sure all fields are filled out accurately without any alterations to the form. Prepare the original and the required number of copies for submission.
10. Finally, submit the form either by mailing it to the Division of Workers’ Compensation or by filing it at one of the Division’s adjudication offices.

Complete your Claim for Compensation form online today to ensure timely processing of your workers' compensation claim.