MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION
REPORT OF SERIOUS INJURY REFERRAL FORM
Please complete this form for an injured worker that you feel may qualify as seriously injured as defined in the Statement of Policy Eligibility Guidelines for Second Injury Fund rehabilitation benefits.
Complete to the best of your knowledge. Injured Worker: Address: Date of Injury: Employer: Address: Treating Physician: Address: Facility Name: Address: Name of Person Referring: Phone Number: Date Treatment Began: Date Treatment Ended (if completed): SSN:
Return completed form to: Fax: 573-522-1623 Phone: 573-526-3876 Mail: Attn: Rhonda Forck Missouri Division of Workers' Compensation P. O. Box 58 Jefferson City, Missouri 65102-0058
Relay Missouri: 1-800-735-2966 (TDD) 1-800-735-2466 (Voice) www.dolir.mo.gov/wc
WCR-6 (07-03) AI