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Get Mo Dwc Wc-21 2014
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How to fill out the MO DWC WC-21 online
This guide provides essential information on how to complete the Missouri Department of Labor and Industrial Relations’ Claim for Compensation form, known as the MO DWC WC-21. By following these steps, users can ensure they properly fill out the form and submit it effectively.
Follow the steps to fill out the MO DWC WC-21 form online.
- Press the ‘Get Form’ button to access the form and open it in your preferred editor.
- Begin filling out the 'Employee Information' section, starting with the injured employee’s name. Be sure to include the last name, first name, and middle initial.
- In Box 2, provide the last four digits of the injured employee's Social Security number.
- Fill out Box 3 with the date of birth of the employee.
- Enter the date of the accident or occupational disease in Box 4.
- For Box 5, include the average weekly wage earned by the employee.
- In Box 6, indicate the time of the accident by marking either A.M. or P.M.
- Complete Box 7 with the place of accident, including city, county, state, and ZIP code.
- Describe the injury specifics in Box 9, explaining what the employee was doing at the time of the incident.
- In Box 10, list the employers against whom the claim is filed and include necessary mailing addresses.
- If filing against the Second Injury Fund, check the appropriate boxes in Box 12 and provide any required information for pre-existing conditions.
- If the injury resulted in death, provide details in Box 14 and list dependents in Box 15.
- Both the injured employee or claimant must sign in Box 16, while an attorney signature is required in Box 19 if applicable.
- Once all sections are completed, save your changes, and print the form. Ensure that the original claim form and the required number of copies are prepared for submission.
Complete your MO DWC WC-21 form online today!
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Filling out the DWC 1 form requires attention to detail, starting with your name and employer’s information. Make sure to include the nature of your injury, symptoms, and any witness accounts. Following the MO DWC WC-21 specifications will ensure you submit a thorough and correct form.
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