Form WC-22-A "Answer to Claim for Compensation" - Missouri

What Is Form WC-22-A?

This is a legal form that was released by the Missouri Department of Labor and Industrial Relations - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2015;
  • The latest edition provided by the Missouri Department of Labor and Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC-22-A by clicking the link below or browse more documents and templates provided by the Missouri Department of Labor and Industrial Relations.

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Download Form WC-22-A "Answer to Claim for Compensation" - Missouri

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd.,
DIVISION OF WORKERS’ COMPENSATION
P.O. Box 58
ANSWER TO CLAIM FOR COMPENSATION
Jefferson City, MO 65102-0058
INSTRUCTIONS
www.labor.mo.gov/DWC
This Answer form is to be used for injuries occurring on or after January 1, 2014.
1) Amended Answer to Claim: If the Answer is being amended, the box number amended must be indicated in the box
“BOX NUMBER(S) AMENDED” in order for the Division to process the amendments to the Answer.
2) If the employer is a corporation or limited liability company, it must file the Answer by and through an attorney who
is admitted to the practice of law in the state of Missouri. If applicable, refer to Missouri Supreme Court Rules, Rule
9, that governs the practice of law by non-resident attorneys. Insurance companies are usually corporations and must
file an Answer by and through an attorney who is admitted to the practice of law in the state of Missouri.
3) File a separate Answer on behalf of each employer against whom the original/amended Claim for Compensation has
been filed. Provide complete information in Boxes 2, 3, and 4 regarding the employer, insurer, and/or third-party
administrator on whose behalf the Answer is being filed.
§
4) If the Answer is filed on behalf of an employer who has purchased a large deductible policy pursuant to
287.310,
RSMo, you MUST provide the name and address of the insurance carrier in order for the Division to accept and
process the Answer. The self-insured employer or group/trust must have been granted self-insurance authority
by the Missouri Division of Workers’ Compensation.
5) If you do not know the name and address of the insurance carrier and you believe that the insurance carrier
information will not be available within thirty (30) days for the Answer to be timely filed pursuant to 8 CSR
50-2.010(8), include on your letterhead a statement that the insurance carrier information will be provided to the
Division as soon as it becomes available. You may indicate on your letterhead that you would like the Division to
enter your appearance on behalf of the employer in order for you to receive the notices on the docket settings.
6) It is the employer’s responsibility to ensure that the workers’ compensation insurance carrier is authorized to insure
such liability in the state of Missouri by the Missouri Department of Insurance, Financial Institutions and
Professional Registration. See §287.280, RSMo. Similarly, the third-party administrator must have a valid certificate
of authority issued by the Missouri Department of Insurance, see §376.1092, RSMo, or otherwise fall within the
provisions of §376.1075 (1), RSMo.
NOTE 1: If the First Report of Injury has been filed with the Division, the insurance carrier name that appears on the
First Report of Injury will be entered by the Division as the carrier that issued the workers’ compensation
insurance policy for the time period that covers the date of injury. If your Answer indicates a different
insurance carrier from the insurance carrier appearing on the First Report of Injury, the Division will add the
insurance carrier that appears on the Answer as a party to the underlying case.
NOTE 2: If the First Report of Injury is not filed with the Division and the proof of coverage filed with the Division
indicates the name and address of the insurance carrier that issued the workers’ compensation insurance policy
for the time period that covers the date of injury, the Division will add this insurance carrier as a party to the
case. If your Answer indicates a different insurance carrier from the insurance carrier appearing on the proof of
coverage, the Division will add the insurance carrier that appears on the Answer as a party to the underlying
case.
If you have any questions, contact the Division’s CARE Unit at 573-526-4948 or you may call the Division toll free at
800-775-2667.
Missouri Division of Workers’ Compensation is an equal opportunity employer/program. Auxiliary aids and services
are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711
WC-22-A (06-15) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd.,
DIVISION OF WORKERS’ COMPENSATION
P.O. Box 58
ANSWER TO CLAIM FOR COMPENSATION
Jefferson City, MO 65102-0058
INSTRUCTIONS
www.labor.mo.gov/DWC
This Answer form is to be used for injuries occurring on or after January 1, 2014.
1) Amended Answer to Claim: If the Answer is being amended, the box number amended must be indicated in the box
“BOX NUMBER(S) AMENDED” in order for the Division to process the amendments to the Answer.
2) If the employer is a corporation or limited liability company, it must file the Answer by and through an attorney who
is admitted to the practice of law in the state of Missouri. If applicable, refer to Missouri Supreme Court Rules, Rule
9, that governs the practice of law by non-resident attorneys. Insurance companies are usually corporations and must
file an Answer by and through an attorney who is admitted to the practice of law in the state of Missouri.
3) File a separate Answer on behalf of each employer against whom the original/amended Claim for Compensation has
been filed. Provide complete information in Boxes 2, 3, and 4 regarding the employer, insurer, and/or third-party
administrator on whose behalf the Answer is being filed.
§
4) If the Answer is filed on behalf of an employer who has purchased a large deductible policy pursuant to
287.310,
RSMo, you MUST provide the name and address of the insurance carrier in order for the Division to accept and
process the Answer. The self-insured employer or group/trust must have been granted self-insurance authority
by the Missouri Division of Workers’ Compensation.
5) If you do not know the name and address of the insurance carrier and you believe that the insurance carrier
information will not be available within thirty (30) days for the Answer to be timely filed pursuant to 8 CSR
50-2.010(8), include on your letterhead a statement that the insurance carrier information will be provided to the
Division as soon as it becomes available. You may indicate on your letterhead that you would like the Division to
enter your appearance on behalf of the employer in order for you to receive the notices on the docket settings.
6) It is the employer’s responsibility to ensure that the workers’ compensation insurance carrier is authorized to insure
such liability in the state of Missouri by the Missouri Department of Insurance, Financial Institutions and
Professional Registration. See §287.280, RSMo. Similarly, the third-party administrator must have a valid certificate
of authority issued by the Missouri Department of Insurance, see §376.1092, RSMo, or otherwise fall within the
provisions of §376.1075 (1), RSMo.
NOTE 1: If the First Report of Injury has been filed with the Division, the insurance carrier name that appears on the
First Report of Injury will be entered by the Division as the carrier that issued the workers’ compensation
insurance policy for the time period that covers the date of injury. If your Answer indicates a different
insurance carrier from the insurance carrier appearing on the First Report of Injury, the Division will add the
insurance carrier that appears on the Answer as a party to the underlying case.
NOTE 2: If the First Report of Injury is not filed with the Division and the proof of coverage filed with the Division
indicates the name and address of the insurance carrier that issued the workers’ compensation insurance policy
for the time period that covers the date of injury, the Division will add this insurance carrier as a party to the
case. If your Answer indicates a different insurance carrier from the insurance carrier appearing on the proof of
coverage, the Division will add the insurance carrier that appears on the Answer as a party to the underlying
case.
If you have any questions, contact the Division’s CARE Unit at 573-526-4948 or you may call the Division toll free at
800-775-2667.
Missouri Division of Workers’ Compensation is an equal opportunity employer/program. Auxiliary aids and services
are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711
WC-22-A (06-15) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
INJURY NUMBER
DIVISION OF WORKERS’ COMPENSATION
3315 West Truman Blvd., P.O. Box 58
Jefferson City, MO 65102-0058
-
+
ANSWER TO CLAIM FOR
COMPENSATION
Box Number(s) Amended
Original
Amended
NOTE: Pursuant to 8 CSR 50-2.010 (8) (A), the Answer must be filed within thirty (30) days from the date the Division acknowledges
receipt of the claim. Submit one original for the Division, one copy for the claimant, and one copy for claimant’s attorney.
Read instructions before completing this form.
1. Injured Employee/Claimant’s Name
1.A. Social Security No.
XXX-XX- _______
1.B. Mailing Address
1.C. City
1.D. State
1.E. ZIP Code
2. Name of Employer or Self-Insured Employer
2.A. Mailing Address
2.B. City
2.C. State
2.D. ZIP Code
3. Name of Insurance Carrier or Self-Insured Group/Trust
3.A. Mailing Address
3.B. City
3.C. State
3.D. ZIP Code
4. Name of Claims Administrator or Third-Party Administrator
4.A. Mailing Address
4.B. City
4.C. State
4.D. ZIP Code
5. Telephone Number of the Insurance Carrier
Telephone Number of Claims Administrator or Third Party Administrator
6. Date of accident/occupational disease.
7. Has the employer/insurer obtained a rating of permanent disability?
Yes
No
8. Name all authorized providers of medical aid:
9. All of the statements or allegations in the claim for compensation are admitted except the following:
Describe below each statement or allegation in the claim for compensation that is being disputed, the reason why it is being disputed, and the
facts in regard thereto. List all affirmative defenses.
If needed, attach sheet with additional information or additional statements.
DIVISION USE ONLY
DATE STAMP
+
WC-22
WC-22-A-2 (06-15) AI
INJURY NUMBER
-
Claim For Compensation alleges occupational disease due to toxic exposure that includes the following: asbestosis, berylliosis, coal worker’s
pneumoconiosis, bronchiolitis obliterans, silicosis, silicotuberculosis, manganism, acute myelogenous leukemia, and myelodysplastic syndrome.
COMPLETE THE FOLLOWING BOXES IF THE INSURANCE CARRIER OR SELF-INSURED GROUP TRUST IS DIFFERENT THAN
THAT INDICATED IN BOXES 3 THROUGH 5 ABOVE.
10. Name of Insurance Carrier or Self-Insured Group/Trust
10.A. Mailing Address
10.B. City
10.C. State
10.D. ZIP Code
11. Name of Claims Administrator or Third-Party Administrator
11.A. Mailing Address
11.B. City
11.C. State
11.D. ZIP Code
12. Telephone Number of the Insurance Carrier
Telephone Number of Claims Administrator or Third Party Administrator
toxic exposure resulting in a diagnosis of mesothelioma
13. If the Claim for Compensation alleges an Occupational Disease due to
,
check one of the following boxes that describes how the EMPLOYER has INSURED his/her LIABILITY:
AN INSURANCE CARRIER
GROUP INSURANCE POOL UNDER §287.223
SELF-INSURANCE APPROVED BY THE DIVISION OF WORKERS’ COMPENSATION
REJECTED MESOTHELIOMA LIABILITY
COMPLETE THE FOLLOWING BOXES IF THE INSURANCE CARRIER OR SELF-INSURED GROUP TRUST IS DIFFERENT THAN
THAT INDICATED IN BOXES 3 THROUGH 5 ABOVE.
14. Name of Insurance Carrier or Self-Insured Group/Trust or MO RISK MESOLTHELIOMA RISK MANAGEMENT FUND
14.A. Mailing Address
14.B. City
14.C. State
14.D. ZIP Code
15. Name of Claims Administrator or Third-Party Administrator
15.A. Mailing Address
15.B. City
15.C. State
15.D. ZIP Code
16. Telephone Number of the Insurance Carrier
Telephone Number of Claims Administrator or Third Party Administrator
17. Employer’s Signature
18. Insurer’s Signature
Date
Date
19. Attorney Signature
19.A. Attorney Name (Type or Print)
19.B. Bar Number
20. Attorney Phone Number
20.A. Attorney Fax Number
20.B. Attorney E-mail Address
21. Attorney Mailing Address
21.A. City
21.B. State
21.C. ZIP Code
WC-22-A-3 (06-15) AI
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