Form WCT-2 "Affidavit Form a - Questions and Affidavit for Claimant Regarding Benefit Sources and Payments" - Missouri

What Is Form WCT-2?

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 April 1, 2012;
  • 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-2 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-2 "Affidavit Form a - Questions and Affidavit for Claimant Regarding Benefit Sources and Payments" - Missouri

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd., P.O. Box 58
TORT VICTIMS’ COMPENSATION
Jefferson City, MO 65102-0058
573-751-4231
QUESTIONS AND AFFIDAVIT FOR CLAIMANT
www.labor.mo.gov/DWC
REGARDING BENEFIT SOURCES AND PAYMENTS –
AFFIDAVIT FORM A
File No:
Claimant’s Name:
(Please type or print your answers. You may use additional sheets if necessary.)
I,
, as part of my claim against the Missouri Tort Victims’
(name of undersigned claimant)
Compensation Fund, hereby answer the following questions truly, accurately and completely.
1. For each policy of insurance insuring the tortfeasor, the tortfeasor’s liability, or the tortfeasor’s vehicle, please state:
a. Name of the insurance company issuing the policy;
b. Named insured under the policy;
c. Coverages and policy limits; and
d. Amounts paid to you, or paid on your behalf, under the policy (without reductions for payments made to your
attorney, to health care providers, or to lienholders).
Attach copies of insurance policies, certificates of insurance, or declarations pages to explain or supplement your
answers.
WCT-2 (04-12) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd., P.O. Box 58
TORT VICTIMS’ COMPENSATION
Jefferson City, MO 65102-0058
573-751-4231
QUESTIONS AND AFFIDAVIT FOR CLAIMANT
www.labor.mo.gov/DWC
REGARDING BENEFIT SOURCES AND PAYMENTS –
AFFIDAVIT FORM A
File No:
Claimant’s Name:
(Please type or print your answers. You may use additional sheets if necessary.)
I,
, as part of my claim against the Missouri Tort Victims’
(name of undersigned claimant)
Compensation Fund, hereby answer the following questions truly, accurately and completely.
1. For each policy of insurance insuring the tortfeasor, the tortfeasor’s liability, or the tortfeasor’s vehicle, please state:
a. Name of the insurance company issuing the policy;
b. Named insured under the policy;
c. Coverages and policy limits; and
d. Amounts paid to you, or paid on your behalf, under the policy (without reductions for payments made to your
attorney, to health care providers, or to lienholders).
Attach copies of insurance policies, certificates of insurance, or declarations pages to explain or supplement your
answers.
WCT-2 (04-12) AI
2. Identify all insurance policies or coverages which afford, or have afforded, or may afford, any coverage for you, or on
your behalf, for any personal injury, property damage, loss of income or earning capacity, or medical bills you
sustained, or allege to have sustained, or believe you will sustain in the future, as a result of the tort forming the basis
of your claim. Such insurance policies or coverages may include, but are by no means limited to: uninsured motorists
coverage, underinsured motorists coverage, collision coverage, medical payments (“med pay”) coverage, health or
medical insurance, health or medical fund, pool or trust, accident and sickness insurance, homeowners insurance,
premises liability insurance, long-term disability insurance, short-term disability insurance, and supplemental
insurance.
For each such policy or coverage, please state:
a. Name of the insurance company issuing the policy, or the name of the fund, pool, or trust;
b. Named insured or member(s);
c. Type(s) of coverage(s) and dollar limits on coverage(s); and
d. Amounts paid to you, or paid on your behalf (without reductions for payments made to your attorney, to
health care providers, or to lienholders).
Attach copies of insurance policies, certificates of insurance, declarations pages, trust agreements or similar
documents to explain or supplement your answers.
3. If your claim (or a portion of your claim) is for the death of a spouse or other relative, identify all life insurance
policies insuring the life of the deceased, and for each such policy, state:
a. Name of the insurance company issuing the policy;
b. Named beneficiary(ies) under the policy;
c. Amount of the policy; and
d. Amounts paid under the policy, and to whom.
Attach copies of documents to explain or supplement your answers.
WCT-2-2 (04-12) AI
4. State whether you have received, are receiving, will receive, or may be eligible to receive, any monetary benefits as a
result (or partial result) of injuries or losses sustained by you as a result of the tort forming the basis of your claim,
from any of the following sources:
a. Missouri Crime Victims’ Compensation Fund, or a similar fund in any other state or jurisdiction;
b. Workers’ Compensation benefits from any state or jurisdiction;
c. Social Security benefits;
d. Tortfeasor or the tortfeasor’s property;
e. Tortfeasor’s estate (i.e., decedent’s estate);
f. Tortfeasor’s conservatorship or guardianship estate;
g. Tortfeasor’s bankruptcy estate or insolvency estate;
h. A trust or estate or which the tortfeasor is a beneficiary;
i. Any insurance guaranty fund or self-insured guaranty fund, including, but not limited to, the Missouri
Property and Casualty Insurance Guaranty Association, the Missouri Private Sector Individual Self-Insurance
Guaranty Corporation, or the Missouri Life and Health Insurance Guaranty Association;
j. A bankruptcy estate, insolvency estate, or receivership for any insurance company insuring the tortfeasor, the
tortfeasor’s liability, or the tortfeasor’s vehicle; or
k. Court-ordered restitution.
For each such source, state the amount(s) you have received, are receiving, or will receive, or the amount(s) you
believe you may be eligible to receive. Attach copies of documents to explain or supplement your answers.
WCT-2-3 (04-12) AI
5. Have you received, or are you receiving, any funds from any third-party (e.g., the tortfeasor’s spouse, the tortfeasor’s
parent) on account of the tort forming the basis of your claim?
Yes
No If “Yes,” identify the source and
amount of all such funds.
6. Have you received any treatment at a Veterans’ Administration medical facility as a result of your injuries?
Yes
No
7. Has Medicaid or Medicare paid for any of the medical treatment you received as a result of your injuries?
Yes
No If “Yes,” attach copies of all correspondence you have received regarding such payments.
8. Have you received, are you receiving, are you entitled to receive, have you applied to receive, or do you anticipate
receiving any funds compensating you for damages you have sustained or will sustain as a result of the tort forming
the basis of your claim, not otherwise identified hereinabove?
Yes
No If “Yes,” set forth the source,
amount and nature of all such payments.
Oath or affirmation. I,
, under oath or affirmation,
(print name)
state that the foregoing answers, statements and representations are true and correct to my best knowledge and belief,
subject to the penalties of making a false affidavit or declaration.
Signature
WCT-2-4 (04-12) AI
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