Fillable Employee Information Missouri Division of Workers Compensation P.O. (Missouri)

Fill Online, Printable, Fillable, Blank Employee Information Missouri Division of Workers Compensation P.O. (Missouri) Form

Use Fill to complete blank online MISSOURI pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Employee Information Missouri Division of Workers Compensation P.O. (Missouri)

On average this form takes 2 minutes to complete

The Employee Information Missouri Division of Workers Compensation P.O. (Missouri) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 8 other fields

Country of origin: US
File type: PDF

BROWSE MISSOURI FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
The Missouri Division of Workers’ Compensation (DWC)
administers programs for workers who have been injured on the
job or exposed to an occupational disease arising out of and in
the course of employment. The Division’s Administrative Law
Judges have the authority to approve settlements or issue awards
after a hearing relating to an injured employee’s entitlement to
benefits.
Steps to Take When Injured on the Job
1. Notify your employer immediately (written notice must be provided within 30 days of the accident/or 30 days after the
diagnosis of any occupational disease or repetitive trauma) by contacting
__________________________________________, _________________________.
employer representative phone number
*Failure to do so may jeopardize your ability to receive benefits
2. Ask your employer to provide medical treatment (your employer/insurer is responsible for providing medical
treatment and paying the medical fees and charges unless you choose to treat with another doctor at your own
expense without your employer/insurer’s approval).
3. Get more information about the benefits available under the Workers’ Compensation Program or about the steps you may
take to get the benefits you need. Visit www.labor.mo.gov/DWC or call 800-775-COMP.
Benefits for Injured Employees
Medical Care:
The employer or insurer is required to provide medical treatment and care that is reasonably required to cure and relieve
the effects of the injury. This includes all costs for authorized medical treatment, prescriptions, and medical devices. There
is no deductible, and all costs are paid by the employer or its workers’ compensation insurance company. If you receive a
bill, contact your employer or the insurance company immediately. The employer/insurer has the right to choose the
healthcare provider or treating physician. You may select a different healthcare provider or treating physician, but if you do
so, it may be at your own expense.
Payment for Lost Wages:
If a doctor says you are unable to work due to your injuries or recovery from a surgery, you may be entitled to temporary
total disability (TTD) benefits. If a doctor says that you can perform light or modified duty work and your employer
offers you such work, you may not be eligible for TTD benefits. TTD benefits should be continued until the doctor says
you can return to work, or when your treatment is concluded because your condition has reached “maximum medical
improvement,” whichever occurs first.
If you return to light or modified duty at less than full pay, you may be entitled to temporary partial disability benefits.
Permanent Disability Benefits:
If the injury or illness results in a permanent disability, you may be entitled to receive either permanent partial or permanent
total disability benefits.
Survivor Benefits:
If a work-related injury causes an employee’s death, the surviving dependents may receive weekly death benefits paid at 66
2/3% of the deceased employee’s average weekly wage along with funeral expenses up to $5,000 from the employer/insurer.
For additional information relating to survivor’s benefits, including college scholarship opportunities for surviving children,
please visit www.labor.mo.gov/DWC.
Additional Benefits for Occupational Diseases Due to Toxic Exposure - Permanent Total Disability and/or Death:
For information relating to additional benefits available, please refer to the Division’s website at www.labor.mo.gov/DWC/
Injured_Workers/benefits_available.
Missouri Division of Workers’ Compensation
P.O. Box 58, Jefferson City, MO 65102
573-751-4231
Employee Information
Insurance Company, Third Party Administrator,
Service Company, or
Designated Individual If Self-Insured
Name _____________________________________________
_____________________________________________
Address ____________________________________________
____________________________________________
____________________________________________
Phone _____________________________________________
**Make sure your data is turned on and scan the QR Code with your smartphone’s camera to go to the Division of Workers Compensation’s Website
for more information. If you are not redirected, you may need to update your smartphone’s operating system or download a QR Code reader app.
With some exceptions, all employers with five or more employees, and construction industry employers with one or more
employees, are required to insure their workers’ compensation liability, either by purchasing a policy or obtaining self-
insurance authority. Workers’ compensation insurance provides benefits to workers injured on the job. Employers also are
required to post this notice in the workplace for employees to view. This poster is required by section 287.127, RSMo, and is
available to employers and insurers free of charge by contacting the Division at 800-775-Comp.
Steps to Take When an Injury Occurs
1. Be sure first aid is administered and the employee is taken to a physician or hospital for further medical care, if necessary.
2. Report the injury to the insurance company or Third Party Administrator (TPA) within five days of the date of injury
or within five days of the date on which the injury was reported to the employer by the employee, whichever is later.
The insurer, TPA, or Division approved self-insurer is responsible for filing a First Report of Injury with the Division of
Workers’ Compensation within 30 days of knowledge of the injury.
3. Pay medical bills related to the work injury for treatment reasonably required to cure and relieve the employee of the
effects of the injury. This includes all costs for authorized medical treatment, prescriptions, and medical devices. The
employer has the right to choose the healthcare provider or treating physician. (The employee may select a different
healthcare provider or treating physician, but if the employee does so, it may be at his/her own expense.)
4. For more liability and insurance information relating to the Workers’ Compensation Program, visit www.labor.mo.gov/
DWC or call 800-775-COMP.
Missouri Division of Workers’ Compensation is an equal opportunity employer/program. Auxiliary aids and services
are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711
Workers’ Compensation Law
Roles and Responsibilities for Employers and Employees
WC-106 (07-19) AI
EMPLOYER INFORMATION
Fraud/Noncompliance
Employee Fraud – knowingly making a claim for workers’ compensation benefits to which an employee knows he/she is
not entitled or knowingly presenting multiple claims for the same occurrence with intent to defraud is a class E felony,
punishable by a fine of up to $10,000, or double the value of the fraud, whichever is greater. A subsequent violation is a
class D felony.
Employer Fraud – knowingly misrepresenting an employee’s job classification or any other fact to obtain insurance at less
than the proper rate is a class A misdemeanor. A subsequent violation is a class E felony. An employer who knowingly
makes a false or fraudulent statement regarding an employee’s entitlement to benefits to discourage the worker from
making a legitimate claim or who knowingly makes a false or fraudulent material statement or material representation to
deny benefits to a worker is guilty of a class A misdemeanor punishable by a fine of up to $10,000. A subsequent violation
is a class D felony.
Insurer Fraud – knowingly and intentionally refusing to comply with workers’ compensation obligations to which an
insurance company or self-insurer knows an employee is entitled is a class E felony, punishable by a fine of up to $10,000
or double the value of the fraud, whichever is greater. A subsequent violation is a class D felony.
Employer Noncompliance – knowingly failing to insure workers’ compensation liability under the law is a class A
misdemeanor punishable by a fine of up to three times the annual premium the employer would have paid had it been
insured or up to $50,000, whichever is greater. A subsequent violation is a class E felony. An employer who willfully fails
to post the notice of workers’ compensation at the workplace is guilty of a class A misdemeanor punishable by a fine of
$50 to $1,000 or by imprisonment or both fine and imprisonment.
Workers’ Safety
Developing and implementing a comprehensive safety and health program can reduce occupational injuries and
help lower workers’ compensation costs. Insurance carriers in the state of Missouri must provide safety assistance
at the request of the insured employer. The Missouri Department of Labor evaluates these services and provides
additional assistance through its Missouri Workers’ Safety Program.
Visit www.labor.mo.gov/MWSP or call 573-751-4231 for more information about these programs or for a registry
of independent consultants who are certified in the state of Missouri to provide safety assistance.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Employee Information Missouri Division of Workers Compensation P.O. (Missouri)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document