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MMMA CLAIMS FORMS |
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The following forms are for use by MMMA Self-Insured Workers’ Compensation Fund members. Completed forms may be sent to us by Email, fax or mail.
Report of Injury—If not reporting via Internet, complete and submit this form for each new injury. (Required by State of Missouri—this form is in an Adobe Acrobat file that may be filled in online, printed and then faxed or mailed to us.)
· PLEASE NOTE: If you have questions about which fields must be completed on the First Report of Injury, select Sample FROI. Those boxes which are highlighted indicate that the information requested must be completed or the state will not accept the claim. There are also some instructions for completion of the form.
How to Report a Claim—Complete and submit for each new injury. This form should also be completed and submitted if there is a change in the claim status. (Required by MMMA Claims Services.)
WC Authorization for Medical Treatment—May be completed and sent with employee to medical facility when he/she is sent for medical treatment.
Return to Work/Physical Capability Form—To be completed by the employer and the physician.
Authorization to Release Medical Records—Must be signed by employee. This gives MMMA Claims Services the ability to request and receive medical records related to the employee’s injury.
Employee Incident/Injury Report—Request injured employee to complete.
Supervisor Incident/Injury Report—Request injured employee’s supervisor to complete.
Witness Statement of Incident/Injury Report—Request witness to injury to complete (if applicable).
Wage Statement—Complete and submit if injured employee is losing time off work due to his/her injury. (Required by MMMA Claims Services—to be sent immediately if the injured employee begins losing time.)
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