Free Questions and Affidavit Regarding Completeness of Medical Information Submitted - Affidavit Form E (WCT-6) - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058

INJURY NUMBER

SUBSTITUTION OF COUNSEL

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, Employee vs. , Employer and , Insurer , Third Party Administrator

Date of Accident/ Occupational Disease:

SUBSTITUTION OF COUNSEL On behalf of the Employee Employer/Insurer Third Party Administrator

COMES NOW, the undersigned attorneys and request substitution of counsel in the above case. Respectfully Submitted, Entering Firm/Attorney or Co-Counsel Signature Attorney Name Law Firm Address Phone No. Fax No. Bar No. E-mail Address Comments/Statements: Withdrawing Firm/Attorney or Co-Counsel Signature Attorney Name Law Firm Address Phone No. Fax No. Bar No. E-mail Address

CERTIFICATE OF SERVICE
I certify that a copy of this Substitution of Counsel was mailed or hand delivered to all parties of record, or if represented by an attorney, to their attorneys of record this day of , 20 . Attorney's Signature Attorney's Name (Printed) Address (if different than above) Bar No. Date

DIVISION USE ONLY

DATE STAMP

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WC-237

WC-237 (11-07) AI