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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONSREPORT OF INJURY. O. Box 58 Jefferson City, MO 651020058 (To complete form, see attached instructions)EMPLOYER (NAME, ADDRESS, INCL ZIP CODE)CARRIER
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How to fill out missouri injury report form

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How to fill out missouri injury report form

01
To fill out the Missouri injury report form, follow these steps:
02
Obtain a copy of the Missouri injury report form. You can usually find this form on the website of the Missouri Department of Labor or your employer may provide you with one.
03
Begin by filling out your personal information. This includes your full name, address, phone number, and email address.
04
Provide details about the injury or accident. Include the date, time, and location of the incident. Describe how the injury occurred and any contributing factors.
05
If there were any witnesses to the incident, provide their names and contact information.
06
Describe the injuries sustained in detail. Include information about any medical treatment received and any ongoing conditions resulting from the injury.
07
If applicable, provide information about your employer and their insurance carrier.
08
Sign and date the form. By signing, you certify that the information provided is true and accurate to the best of your knowledge.
09
Make a copy of the completed form for your records and submit the original to the appropriate party, such as your employer or the Missouri Department of Labor.
10
Please note that this is a general guide and specific instructions may vary depending on the specific Missouri injury report form you are filling out. It is always a good idea to carefully read and follow the instructions provided with the form.
11
If you have any concerns or questions about filling out the Missouri injury report form, it is recommended to consult with a legal professional for guidance.

Who needs missouri injury report form?

01
Anyone who experiences an injury or accident in the state of Missouri may need to fill out the Missouri injury report form. This includes employees who have been injured at work, individuals who have been involved in a personal injury accident, and individuals seeking workers' compensation benefits. It is important to check with your employer or legal advisor to determine if you are required to fill out this form based on your specific situation.
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The Missouri injury report form is a document used to report workplace injuries and illnesses.
Employers in Missouri are required to file the injury report form.
The form must be filled out with details of the injury or illness, including date, time, location, and description.
The purpose of the form is to track workplace injuries and illnesses for record-keeping and safety improvement.
Information such as the name of the injured employee, nature of the injury, and treatment provided must be reported.
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