Missouri > Workers Comp

Application For Tort Victims Compensation WCT-1 - Missouri

Application For Tort Victims Compensation Form. This is a Missouri form and can be used in Workers Comp .
 Fillable pdf Last Modified 5/12/2005
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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS COMPENSATION APPLICATION FOR TORT VICTIMS COMPENSATION ORIGINAL AMENDED For Office Use Only INSTRUCTIONS: 1. Type or Print clearly in ink. Claim No. 2. Last page of this form must be signed by claimant and notarized. 3. If claimant is incapacitated or disabled or a minor person, application MUST be made by a parent, guardian or conservator or persons spouse. 4. If a question is NOT APPLICABLE answer with N/A. 5. Claim to be filed in person or by mail. MAILING ADDRESS TELEPHONE NUMBER RELAY MISSOURI TORT VICTIMS COMPENSATION PROGRAM (573) 751-4231 1-800-735-2966 (TDD) P.O. BOX 58, JEFFERSON CITY, MO 65102-0058 1-800-735-2466 (VOICE) Claimant Name (Last, First, Middle) Relationship to Victim Social Security Number Current Street Address City State Zip Code Home Telephone Number Work Telephone Number Was Victim living with you at the time of injury or death? Yes No Victims Name (Last, First, Middle) Victims Address Social Security Number Birthdate Is Victim deceased? Dependents of Victim(Name, Address, Date of Birth) (Use additional sheet if necessary.) Yes No Age Sex Male Female Date Tort Committed Nature of Tort Committed Briefly describe the injury(ies) sustained by the victim Is the victim or the claimant currently incarcerated Was the victim on house arrest and confined in any Has the victim pled guilty or been found guilty of 2 or for a crime unrelated to this application for federal, state, regional, county or municipal jail, prison or more felonies either involving a controlled substance compensation? other correctional facility at the time of injury? or an act of violence within the past ten years? Yes No Yes No Yes No Brief description of the felonies State or Local Agency, including a prosecuting attorney or law enforcement agency where the crime was reported Date of Incident Defendants Name Victims Employers Name Telephone Number Address City State Zip Code Is the victim a party in personal injury or wrongful death Has the victim obtained a final monetary judgment in the lawsuit? lawsuit? Yes No Yes No (If the answer is No and the claimant is requesting a waiver, please complete attached statements.)Name and address of the court where the judgment was entered Is the final monetary Name and address of the court where the appeal is pending judgment being appealed? Yes No List all other sources for claimant or dependent to receive any benefit, payment of award as a result of the injury or death WCT-1 (08-04) AI <<<<<<<<<********>>>>>>>>>>>>> 2Names and address of all hospitals, physicians or surgeons who treated or examined the victim for the injury or resulting death at the case may be. (Use additional sheets if necessary.) Insurance information covering the liability of the tortfeasor: Insurance Name Policy Number Street Address City State Zip Code Name of Policy Holder Effective Date of Policy/Coverage Policy Limits if known It is not necessary to retain any attorney; however, you may have an attorney represent you in this claim. Attorney Name Telephone Number Address City State Zip Code AUTHORIZATION FOR RELEASE OF INFORMATION TO CONDUCT AN INVESTIGATION, AND ASSIGNMENT OF SUBROGATION RIGHTS I give permission to any hospital, physician, funeral home, law enforcement agency, insurance company, employer welfareal agen or soccy,i or any federal, state or local government agency to release all records and information that will help the Missouri Tort Victim Compensation Unit to process my claim for compensation, to allow copies of such records to be made and to answer any questions made by or onof the Missouri behalf Tort Victims Compensation Unit. I understand that after receiving this form, the Missouri Tort Victims Compensation Unit will investigate the truth of the information provided as well as other matters regarding this claim; and I consent to such investigation. This authorization is valid for two m tyears frohe date given below. I acknowledge and agree that the State of Missouri is subrogated, to the extent of any compensation awarded to me, laimants rights to all the cto recover benefits or advantages for economic loss from a source which is, or if readily available to the victim or claimant would be, a collateral source, and I hereby assign such rights to the State of Missouri at it may protect so thits subrogation rights, and agree to sist the state in pursuing asits subrogation right. I agree to notify the Division if I retain any attorney to represent me in a lawsuit related to this tort. I also agrifey the e to notDivision: 1) in the event I receive restitution payment from the tortfeasors agent, or 2) in the event I initiate any legal proceeding orions neto rgotieacover dtamages related to the tort upon which this claim is based. I certify that I have read and understand the statements above; and that the information I have given is true and correct toe best of m thy knowledge and belief and that these benefits will be denied if any such statements are not true. Signature of Claimant Date If the victim is under 18 years of age, this application must be signed by the parent or legal guardian. On this __________ day of _____________________ 20___, before me personally appeared ______________________________, to be known to be the person described in and who executed the foregoing Tort Victims Compensation Application and acknowledged that thcuted they exee same as their free act and deed. And said applicant declares that the information providis ed true and correct to the best of their knowledge. Subscribed and sworn to before me the day and year first above written. _____________________________________________________ My commission expires: (Notary Seal) WCT-1-2 (08-04) AI <<<<<<<<<********>>>>>>>>>>>>> 3 WHO CAN APPLY? The following persons are eligible for compensation a) an uncompensated tort victim; and b) if the uncompensated tort victim is deceased as a direcresult oft the tort, the class of persons specified in Section 5380 (1); and 7.0 c) any relative of the uncompensated tort victim who legassumes the oblly aligation for, or who incurred medical or burial expenses, as a direct result of the tort. WHAT REQUIREMENTS MUST BE MET?  An uncompensated tort victim is a person who: d) Is a party in a personal injury or wrongful death lawsuit; or is a tort victim whose claim against the tortfeasor heattls bed foreen s the policy limits of insurance covering the liability of such t
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