Claim For Compensation After 12-31-13 {WC-21-A}

WC-21-A - CLAIM FOR COMPENSATION. This form is used in Missouri to file a workers’ compensation claim for accident or injury including occupational diseases and occupational diseases due to toxic exposure that occur on or after January 1, 2014.. It must be completed in full, typed or printed in black ink, and submitted with an original and three copies. The form collects detailed information about the injured employee, employer(s), date and location of the accident, body parts affected, and the nature of the injury or illness. If the claim involves toxic exposure-related diseases or mesothelioma, specific checkboxes must be selected. The form also allows dependents to be listed in cases where the injury resulted in death. Additionally, claimants can indicate if they are seeking benefits from the Second Injury Fund for permanent total disability. www.FormsWorkflow.com