Questions And Affidavit Regarding Completeness Medical Information Submitted Affidavit Form E {WCT-6}

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS TORT VICTIMS' COMPENSATION QUESTIONS AND AFFIDAVIT FOR CLAIMANT REGARDING COMPLETENESS OF MEDICAL INFORMATION SUBMITTED ­ AFFIDAVIT FORM E File No: Claimant's Name: 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC (Please type or print your answers. You may use additional sheets if necessary.) I, (name of undersigned claimant) , as part of my claim against the Missouri Tort Victims' Compensation Fund, hereby answer the following questions truly, accurately and completely. Have you submitted to the Missouri Division of Workers' Compensation Tort Victims' Compensation ALL medical records (except for x-ray films and other diagnostic films) and ALL medical reports bearing upon the injuries you allege you have sustained as a result of the tort forming the basis of your claim? Yes No Comment: If no, attach all medical records and reports you have not heretofore submitted to the Missouri Division of Workers' Compensation Tort Victims' Compensation. Identify, in detail, the nature of the medical records or reports not previously submitted, or submitted herewith, and the reason(s) why same have not been submitted. Oath or affirmation. I, (print name) , under oath or affirmation, state that the foregoing answers, statements and representations are true and correct to my best knowledge and belief, subject to the penalties of making a false affidavit or declaration. Signature WCT-6 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com