MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS INJURY NUMBER JOINT MOTION FOR CHANGE OF VENUE 3315 West Truman Blvd., P.O. Box 58, Jefferson City, MO 65102-0058 www.labor.mo.gov/DWC - _________________________________, Employee Vs _________________________________, Employer And _________________________________, Insurer/Third Party Administrator ) ) ) ) ) ) ) ) ) ) ) Current Case Venue: ___________________________________ Date of Accident/ Occupational Disease: ___________________________ Venue Change Granted: ______________________________________________ Administrative Law Judge: Signature Date: _________________________________________ Venue Transferred To: __________________________ + Joint Motion for Change of Venue The parties jointly submit this motion for change of venue. Pursuant to �287.640.2, RSMo all parties agree that venue of this claim for compensation be transferred to: ____________________________________________________________ Reason for request: _________________________________________________________________________________ Is the Second Injury Fund a party to the case? Yes No Yes No Has the Missouri Attorney General's Office agreed to this Joint Motion for Change of Venue? Respectfully Submitted, + Attorney for Employer/ Insurer/Third Party Administrator Signature _______________________________________ Attorney Name __________________________________ Law Firm _______________________________________ Address ________________________________________ Telephone No. ___________________________________ Bar Number _____________________________________ E-mail Address __________________________________ Missouri Attorney General's Office for Treasurer of state of Missouri as custodian of the Second Injury Fund ___________________________________________ Assistant Attorney General: Signature Line Attorney for Employee Signature _____________________________________ Attorney Name ________________________________ Law Firm _____________________________________ Address ______________________________________ Telephone No. _________________________________ Bar Number ___________________________________ E-mail Address ________________________________ Claimant signature if not represented by an attorney ____________________________________________ Claimant: Signature Line + WC-281 (03-12) AI American LegalNet, Inc. www.FormsWorkFlow.com