Joint Motion For Change Of Venue {WC-281}

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS INJURY NUMBER JOINT MOTION FOR CHANGE OF VENUE 3315 West Truman Blvd., P.O. Box 58, Jefferson City, MO 65102-0058 www.labor.mo.gov/DWC - _________________________________, Employee Vs _________________________________, Employer And _________________________________, Insurer/Third Party Administrator ) ) ) ) ) ) ) ) ) ) ) Current Case Venue: ___________________________________ Date of Accident/ Occupational Disease: ___________________________ Venue Change Granted: ______________________________________________ Administrative Law Judge: Signature Date: _________________________________________ Venue Transferred To: __________________________ + Joint Motion for Change of Venue The parties jointly submit this motion for change of venue. Pursuant to §287.640.2, RSMo all parties agree that venue of this claim for compensation be transferred to: ____________________________________________________________ Reason for request: _________________________________________________________________________________ Is the Second Injury Fund a party to the case? Yes No Yes No Has the Missouri Attorney General's Office agreed to this Joint Motion for Change of Venue? Respectfully Submitted, + Attorney for Employer/ Insurer/Third Party Administrator Signature _______________________________________ Attorney Name __________________________________ Law Firm _______________________________________ Address ________________________________________ Telephone No. ___________________________________ Bar Number _____________________________________ E-mail Address __________________________________ Missouri Attorney General's Office for Treasurer of state of Missouri as custodian of the Second Injury Fund ___________________________________________ Assistant Attorney General: Signature Line Attorney for Employee Signature _____________________________________ Attorney Name ________________________________ Law Firm _____________________________________ Address ______________________________________ Telephone No. _________________________________ Bar Number ___________________________________ E-mail Address ________________________________ Claimant signature if not represented by an attorney ____________________________________________ Claimant: Signature Line + WC-281 (03-12) AI American LegalNet, Inc. www.FormsWorkFlow.com