A list of the Division s adjudication offices may be obtained from the website www. labor. mo. gov/DWC/contact. P. O. Box 58 Jefferson City MO 65102-0058 www. labor. mo. gov/DWC Completed copies of the Claim forms may be mailed to the Division of Workers Compensation P. Please visit the Division s website www. labor. mo. gov/DWC which contains additional information including the full text of the applicable Missouri Workers Compensation Statutes and Regulations as well as many other forms and brochures. If you handwrite or print the information on the Claim form it must be legible to meet the Division s requirements for the record to be electronically stored. You also have the option of completing the Claim form online by typing the information needed in each field printing the form and mailing it to the Division s Jefferson City office or filing it in one of the adjudication offices. 4. Amended Claim If the Claim including the Claim that is being filed against the Second Injury Fund i....
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the MO DWC WC-21 online
The MO DWC WC-21 form is essential for individuals seeking to claim compensation for workplace injuries or occupational diseases in Missouri. This guide provides clear and supportive instructions on how to complete the form online, ensuring that you understand each section thoroughly.
Follow the steps to accurately fill out the MO DWC WC-21 form online.
- Press the ‘Get Form’ button to access the MO DWC WC-21 and open it in your online form editor.
- Begin by filling in the employee's information in the designated fields. Include the employee’s full name, mailing address, social security number (last four digits), date of birth, and the date of the accident or occupational disease.
- In Box 5, provide the average weekly wage. Ensure you fill in gross wages earned rather than net wages.
- For Box 7, indicate the exact location of the accident by specifying the city, county, state, and ZIP code.
- Clearly describe the nature of the injury, including the part(s) of the body injured and the circumstances surrounding the accident in the respective fields provided.
- If applicable, list employers against whom the claim is being filed in Box 10. Ensure to provide mailing addresses for all listed employers.
- If you are filing a claim against the Second Injury Fund, check the appropriate box in Box 12 and fill out any additional required information.
- Complete Box 15 if the injury resulted in death, and provide information about the dependents.
- Ensure that all required fields are filled in and review the form for legibility. If you handwrite any information, it must be clear.
- Finally, sign Box 16 to certify the information provided. If you are represented by an attorney, they must sign Box 19. Save your changes, then download, print, or share the form as necessary before submission.
Complete your MO DWC WC-21 form online to ensure your claim is processed efficiently.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
The updated or current version of the Claim for Compensation form WC-21 may be ... Please...
DWC = Direct Wire Connector. • EXT = Light Extender ... MO = Soft Touch Moss Grey ... WV...
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.
This form is available in several versions. Select the version you need from the drop-down list below.