MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS REPORT OF SERIOUS INJURY REFERRAL FORM SECOND INJURY FUND 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC 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: Physical Rehabilitation Missouri Division of Workers' Compensation P. O. Box 58 Jefferson City, MO 65102-0058 WCR-6 (10-11) AI American LegalNet, Inc. www.FormsWorkFlow.com