This is one of the official workers' compensation forms for the the state of Missouri
Kansas City Missouri Claim for Compensation for Workers' Compensation
Category:
State:
Missouri
City:
Kansas City
Control #:
MO-21-WC
Format:
PDF
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Description
How to fill out Missouri Claim For Compensation For Workers' Compensation?
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FAQ
An employer or its insurer must report the injury, other than an injury that requires immediate first aid and no further medical treatment or lost time from work, to the Division of Workers' Compensation within 30 days after knowledge of the injury.
Failure to report your injury to your employer within 30 days may jeopardize your ability to receive workers' compensation benefits. Notify your employer in writing; the written notice must state the date, time and place of the injury, the nature of the injury and the name and address of the person injured.
The benefits are calculated at 66 2/3% of the employee's average weekly earnings as of the date of the injury, not to exceed a maximum amount set by the law. However, if you suffer from a permanent partial disability, you may receive a lump-sum payment based upon the nature and extent of the disability.
Generally your compensation rate will be equal to 2/3 of your average weekly wage at the time of the injury not to exceed a maximum rate which is presently 55% of the state average weekly wage (?SAWW?).
The employer is responsible for completing the First Report of Injury (FROI) form and submitting it to its workers' compensation insurance company within 10 days of the first day of disability or the date they were aware of disability, whichever is later.
An employer or its insurer must report the injury, other than an injury that requires immediate first aid and no further medical treatment or lost time from work, to the Division of Workers' Compensation within 30 days after knowledge of the injury.
If you wish to file a workers' compensation claim, complete the Claim for Compensation and mail it to the Division (the address is included on the form). This form may also be obtained at any office of the Division of Workers' Compensation.