Form WCT-1 "Tort Victims' Compensation Claim" - Missouri

What Is Form WCT-1?

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 August 1, 2014;
  • 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 WCT-1 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 WCT-1 "Tort Victims' Compensation Claim" - Missouri

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
TORT VICTIMS’ COMPENSATION CLAIM
ORIGINAL
AMENDED
For Office Use Only
1. Print clearly in ink.
INSTRUCTIONS:
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 person’s 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
Missouri TTY User:
TORT VICTIMS’ COMPENSATION PROGRAM
573-751-4231
800-735-2966 or
P.O. BOX 58, JEFFERSON CITY, MO 65102-0058
711 for Relay Missouri
Claimant Name (Last, First, Middle)
Relationship to Victim
Social Security No.
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
Victim’s Name (Last, First, Middle)
Victim’s Address
Social Security No.
Dependents of Victim (Name, Address, Date of Birth) (Use additional sheet if necessary.)
Birthdate
Is Victim deceased?
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
Was the victim on house arrest and confined in any
Has the victim pled guilty or been found guilty of
currently incarcerated for a crime
federal, state, regional, county or municipal jail,
two or more felonies either involving a controlled
unrelated to this application for
prison or other correctional facility at the time of
substance or an act of violence within the past 10
compensation?
injury?
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
Defendant’s Name
Date of Incident
Victim’s Employer’s Name
Telephone Number
Address
City
State
ZIP Code
Is the victim a party in personal injury or
Has the victim obtained a final monetary judgment in the lawsuit?
wrongful death lawsuit?
Yes
No
(If the answer is “No” and the claimant is requesting a waiver, complete attached statements.)
Yes
No
Name and address of the court where the judgment was entered
Is the final monetary
Name and address of the court
judgment being
where the appeal is pending
appealed?
Case Number
Circuit Court of
Yes
No
WCT-1 (08-14) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
TORT VICTIMS’ COMPENSATION CLAIM
ORIGINAL
AMENDED
For Office Use Only
1. Print clearly in ink.
INSTRUCTIONS:
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 person’s 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
Missouri TTY User:
TORT VICTIMS’ COMPENSATION PROGRAM
573-751-4231
800-735-2966 or
P.O. BOX 58, JEFFERSON CITY, MO 65102-0058
711 for Relay Missouri
Claimant Name (Last, First, Middle)
Relationship to Victim
Social Security No.
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
Victim’s Name (Last, First, Middle)
Victim’s Address
Social Security No.
Dependents of Victim (Name, Address, Date of Birth) (Use additional sheet if necessary.)
Birthdate
Is Victim deceased?
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
Was the victim on house arrest and confined in any
Has the victim pled guilty or been found guilty of
currently incarcerated for a crime
federal, state, regional, county or municipal jail,
two or more felonies either involving a controlled
unrelated to this application for
prison or other correctional facility at the time of
substance or an act of violence within the past 10
compensation?
injury?
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
Defendant’s Name
Date of Incident
Victim’s Employer’s Name
Telephone Number
Address
City
State
ZIP Code
Is the victim a party in personal injury or
Has the victim obtained a final monetary judgment in the lawsuit?
wrongful death lawsuit?
Yes
No
(If the answer is “No” and the claimant is requesting a waiver, complete attached statements.)
Yes
No
Name and address of the court where the judgment was entered
Is the final monetary
Name and address of the court
judgment being
where the appeal is pending
appealed?
Case Number
Circuit Court of
Yes
No
WCT-1 (08-14) AI
List all other sources for claimant or dependent to receive any benefit or payment of award as a result of the injury or death
Names and address of all hospitals, physicians, or surgeons who treated or examined the victim for the injury or resulting death as 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 welfare or social agency, or any
federal, state or local government agency to release all records and information that will help the Missouri Tort Victims’ 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 on behalf of the Missouri
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 years from the date given below.
I acknowledge and agree that the State of Missouri is subrogated, to the extent of any compensation awarded to me, to all the claimant’s rights to
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 so that it may protect its subrogation rights, and agree to assist the state in pursuing
its 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 agree to notify the Division: 1) in the
event I receive restitution payment from the tortfeasor’s agent, or 2) in the event I initiate any legal proceeding or negotiations to recover damages
related to the tort upon which this claim is based.
I certify that I have read and understand the statements above; that the information I have given is true and correct to the best of my 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 they executed
the same as their free act and deed. And said applicant declares that the information provided is 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 (08-14) AI
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 direct result of the tort:
i)
the class of persons specified in Section 537.080 (1), RSMo; and
ii)
any relative of the uncompensated tort victim who legally assumes the obligation for, or who incurred medical or burial expenses,
as a direct result of the tort.
WHAT REQUIREMENTS MUST BE MET?
1. An uncompensated tort victim is a person who:
a)
Is a party in a personal injury or wrongful death lawsuit; or is a tort victim whose claim against the tortfeasor has been settled for the
policy limits of insurance covering the liability of such tortfeasor and such policy limits are inadequate in light of the nature and extent
of damages due to the personal injury or wrongful death;
b)
Unless described in paragraph (a) of this subdivision:
a.
Has obtained a final monetary judgment in a lawsuit, as described in paragraph (a) immediately above, against a tortfeasor for
personal injuries or wrongful death and all appeals are final;
b.
Has exercised due diligence in enforcing the judgment; and
c.
Has not collected the full amount of the judgment;
c)
Is not a corporation, company, partnership, or other incorporated or unincorporated commercial entity;
d)
Is not any entity claiming a right of subrogation;
e)
Was not on house arrest and was not confined in any federal, state, regional, county or municipal jail, prison or other correctional
facility at the time he or she sustained injury from the tortfeasor;
f)
Has not pleaded guilty to or been found guilty of two or more felonies, where such two or more felonies occurred within ten years of
the occurrence of the tort in question, and where either of such felonies involved a controlled substance or an act of violence; and
g)
Is a resident of the state of Missouri or sustained personal injury or death by a tort which occurred in the state of Missouri.
2. The claim shall be filed with the Division of Workers’ Compensation not later than two years after the judgment upon which the claim is
based becomes final and all appeals are final. If there is no judgment, the claim must be filed within five years as provided in Section
516.120, RSMo, except in cases resulting in death, where the claim must be filed within three years after the cause of action accrues as
provided in Section 537.100, RSMo.
3. If the uncompensated tort victim is found personally liable on a cross-complaint of tort, or found to be contributorily or comparatively
negligent, compensation shall be limited to the extent of the favorable net amount awarded by the judge or jury.
Missouri Division of Workers’ Compensation is an equal opportunity employer/program.
Auxiliary aids and services are available upon request to individuals with disabilities.
WCT-1-3 (08-14) AI
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