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Get Mo Dwc Wc-21 2015

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 is being amended the Box containing the amended information must be identified in the Box ITEM NUMBER S AMENDED in order for the Division to process the amendments to the Claim. 5. Copies If you are mailing the Claim form to the Division at P. O. Box 58 Jefferson City MO 65102-0058 you need to submit the original and 3 copies of the Claim. If the Claim is being filed against more than 3 employers please submit additional copies to enable the Division to forward the Claims to all employers named. If the Second Injury Fund is named as a party please submit an original and 4 copies. MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS COMPENSATION INSTRUCTIONS FOR COMPLETING CLAIM FOR COMPENSATION 3315 West Truman Blvd. O. Box 58 Jefferson City MO 65102-0058. Please see No* 5 below. You also have the option of filing the Claim form with any of the Division s adjudication offices. asp* Please note that if you decide to file a Claim the Division must receive the Claim form within the time period explained below Within two years from the date of injury or death or within two years from the last payment made on account of the injury or death by the employer or its workers compensation insurance carrier whichever is later OR If the employer does not timely file a First Report of Injury with the Division within three years from the date of injury or death or within three years from the last payment made on account of the injury or death by the employer or its workers compensation insurance carrier whichever is later. As indicated in 287. 063 RSMo in cases of occupational disease the statute of limitation does not begin to run until it becomes reasonably discoverable and apparent that an injury has been sustained related to such exposure. IMPORTANT CONSIDERATIONS 1. Updated Claim form to be used The Division s form must be submitted as an original document in the most current version* The updated or current version of the Claim for Compensation form WC-21 may be downloaded from the Division s website free number 800-775-2667 or by calling one of the local offices.

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