Missouri > Workers Comp
Request For Conference WC-182 - Missouri
| Request For Conference Form. This is a Missouri form and can be used in Workers Comp . |
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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 www.labor.mo.gov/DWC 1. INJURY NUMBER REQUEST FOR CONFERENCE + - Please be advised that corporations and limited liability companies appearing before the Division must be represented by an attorney licensed in the State of Missouri. See Reed v. Labor and Ind. Rel. Commn., 789 S.W. 2d 19, 20 (Mo. banc 1990). 2. Date of Injury Note: This form must be completed in its entirety and must be typed or hand printed in black ink. Please submit this form to the appropriate adjudication office. 4. Employee 5. Address of Employee 3. Case Venue 6. Employee's Telephone No. 7. Attorney for Employer/Insurer 8. Address of Employer/Insurer Attorney 9. Employer/Insurer Attorney's Telephone No. 10. Insurance Company and/or Third Party Administrator 11. Address of Insurance Company or Third Party Administrator, if known 12. Party Requesting the Conference 13. Please explain why you want a conference: Signature of Party Requesting the Conference Employee Attorney Representing the employer or insurer or third party administrator ATTORNEYS REQUESTING CONFERENCE Please check applicable box: Entry of Appearance has been filed with the Division. Entry of Appearance is being filed with this form, and a copy of this form has been mailed to the employee. Please note that a copy of your Entry of Appearance along with a copy of the Request for Conference must be mailed to all parties to the proceeding, including a pro se employee. An administrative law judge cannot act as an attorney for any party or give any specific legal advice to any party regarding the case. An administrative law judge shall approve a settlement agreement as long as: The settlement is not the result of undue influence or fraud; The employee fully understands his or her rights and benefits; The employee voluntarily agrees to accept the terms of the agreement; and The settlement is in accordance with the rights of the parties. COMPLETED BY DIVISION OF WORKERS' COMPENSATION Approved ______________________ Date __________________________ Please visit our website at www.labor.mo.gov/DWC if you have any questions about your rights or benefits under the Workers' Compensation Law. Keep a copy for your records. DIVISION USE ONLY + WC-182 WC-182 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com
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