MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION
APPLICATION FOR TORT VICTIMS' COMPENSATION
ORIGINAL INSTRUCTIONS: AMENDED
For Office Use Only Claim No.
1. Type or Print clearly in ink. 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.
TELEPHONE NUMBER (573) 751-4231 Relationship to Victim City Work Telephone Number Victim's Address State
MAILING ADDRESS TORT VICTIMS' COMPENSATION PROGRAM P.O. BOX 58, JEFFERSON CITY, MO 65102-0058 Claimant Name (Last, First, Middle) Current Street Address Home Telephone Number Victim's Name (Last, First, Middle) Birthdate Age Date Tort Committed Is Victim deceased?
RELAY MISSOURI 1-800-735-2966 (TDD) 1-800-735-2466 (VOICE) Social Security Number Zip Code
Was Victim living with you at the time of injury or death?
Social Security Number
Dependents of Victim (Name, Address, Date of Birth) (Use additional sheet if necessary.)
Nature of Tort Committed
Briefly describe the injury(ies) sustained by the victim
Is the victim or the claimant currently incarcerated Was the victim on house arrest and confined in any for a crime unrelated to this application for federal, state, regional, county or municipal jail, prison or compensation? other correctional facility at the time of injury?
Has the victim pled guilty or been found guilty of 2 or more felonies either involving a controlled substance or an act of violence within the past ten years?
Brief description of the felonies
State or Local Agency, including a prosecuting attorney or law enforcement agency where the crime was reported
Date of Incident Victim's Employer's Name Address
Defendant's Name Telephone Number City State Zip Code
Is the victim a party in personal injury or wrongful death lawsuit?
Has the victim obtained a final monetary judgment in the lawsuit?
Is the final monetary judgment being appealed?
(If the answer is "No" and the claimant is requesting a waiver, please complete attached statements.) Name and address of the court where the appeal is pending
Name and address of the court where the judgment was entered
List all other sources for claimant or dependent to receive any benefit, payment of award as a result of the injury or death
WCT-1 (08-04) AI
Names and address of all hospitals, physicians or surgeons who treated or examined the victim for the injury or resulting death at the case may be. (Use additional sheets if necessary.)
Insurance information covering the liability of the tortfeasor:
Insurance Name Street Address Name of Policy Holder City Effective Date of Policy/Coverage State Policy Limits if known Policy Number Zip Code
It is not necessary to retain any attorney; however, you may have an attorney represent you in this claim.
Attorney Name Address City State Telephone Number 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 Victim 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; and 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:
WCT-1-2 (08-04) AI
WHO CAN APPLY?
The following persons are eligible for compensation a) b) c) an uncompensated tort victim; and if the uncompensated tort victim is deceased as a direct result of the tort, the class of persons specified in Section 537.080 (1); and 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?
An uncompensated tort victim is a person who: d) 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; Unless described in paragraph (a) of this subdivision: 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; Has exercised due diligence in enforcing the judgment; and Has not collected the full amount of the judgment;
b. c. f) g) h) i) j)
Is not a corporation, company, partnership or other incorporated or unincorporated commercial entity; Is not any entity claiming a right of subrogation; 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; 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 Is a resident of the state of Missouri or sustained personal injury or death by a tort which occurred in the state of Missouri.
The "Initial Claims Periods" is the period beginning on August 28, 2001, and ending on December 31, 2002 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, except with respect to the initial claims period. If there is no judgment, the claim must be filed within five years as enumerated in Section 516.120, except in cases resulting in death, where the claim must be filed within three years after the cause of action accrues as enumerated in Section 537.100; except with respect to the initial claims period. With respect to the initial claims period, a claim may be filed with the Division of Workers' Compensation based upon a judgment that is not expired or based upon a claim not reduced to judgment pursuant to Section 537.678 (2) and which would not be barred by the applicable statute of limitation if the tortfeasor could be served with process or had not filed for bankruptcy. 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.
WCT-1-3 (08-04) AI