Get Mo Dwc Wc-21 2015

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.

1. Press the ‘Get Form’ button to access the MO DWC WC-21 and open it in your online form editor.
2. 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.
3. In Box 5, provide the average weekly wage. Ensure you fill in gross wages earned rather than net wages.
4. For Box 7, indicate the exact location of the accident by specifying the city, county, state, and ZIP code.
5. 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.
6. If applicable, list employers against whom the claim is being filed in Box 10. Ensure to provide mailing addresses for all listed employers.
7. 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.
8. Complete Box 15 if the injury resulted in death, and provide information about the dependents.
9. Ensure that all required fields are filled in and review the form for legibility. If you handwrite any information, it must be clear.
10. 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.