Missouri > Workers Comp
Request For Pre-Hearing WC-183 - Missouri
| Request For Pre-Hearing 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 PRE-HEARING + 2. Date of Injury 5. Case Venue 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. 3. Employee 4. Address of Employee 6. Attorney for Employee 7. Address of Employee's Attorney 8. Second Injury Fund Involved Yes 9. Attorney for Employer/Insurer 10. Address of Employer/Insurer Attorney No 11. Name of Second Injury Fund Attorney 12. Insurance Company and/or Third Party Administrator 13. Address of Insurance Company or Third Party Administrator, if known 14. Party Requesting the Pre-Hearing 15. Please briefly state your reason(s) for requesting the pre-hearing: CERTIFICATE OF SERVICE I, the undersigned, certify that a copy of this request has been mailed or hand-delivered to all attorneys and/or parties of record on this day of , 20 . Attorney's signature Attorney's Name (Printed) Address Bar Number Date Telephone Number 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 __________________________ DIVISION USE ONLY + 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. WC-183 WC-183 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com
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