MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS’ COMPENSATION 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 1. INJURY NUMBER REQUEST FOR HEARING – HARDSHIP OR §287.203 HARDSHIP HEARING - + Please check which hearing is requested: §287.203 Other Note: This form must be completed in its entirety and must be typed or hand printed in black ink. 2. Date of Injury Please submit this form to the appropriate adjudication office. 3. Employee 4. Attorney for Employee 5. Case Venue 6. Party Requesting the Hearing 7. Employer(s)/Insurer(s) 8. Attorney for Employer/Insurer 9. Second Injury Fund Involved Yes No 10. Attorney for Second Injury Fund 11. Please state all issues to be resolved by hearing. 11a. The party requesting the hearing has conferred with all attorneys of record, whose names are listed here, regarding disputed issues and listed them above. 12. Has all necessary discovery been completed? Yes No 12a. Are parties prepared to present their evidence at hearing? Yes No (The administrative law judge will consider a hearing request upon completion of discovery and parties’ preparedness to present evidence at hearing.) 13. The party requesting the hearing has conferred with the other attorney of record and estimates the hearing will last approximately hour(s). 14. The party requesting a hearing must provide all exclusionary dates after conferring with all attorneys of record for all offices except Kansas City. The Exclusionary dates are 15. For cases venued in Jefferson City and Joplin, the party requesting the hearing has contacted the applicable office’s docket clerk for available dates and has made a good faith effort to discuss these available dates with the other attorneys of record. Based on this information, the following dates, in order of preference, are requested for a hearing: CERTIFICATE OF SERVICE I, the undersigned, certify that, to the best of my knowledge, information and belief, the information set forth in this Request for Hearing is true and accurate, and I further certify that a copy of this Request for Hearing has been mailed or hand-delivered to all attorneys and/or parties of record this day of , 20 . DIVISION USE ONLY Attorney’s signature Bar Number Date Attorney’s Name (Printed) Address Telephone Number COMPLETED BY DIVISION OF WORKERS’ COMPENSATION Approved Denied By Date Please visit our web site at www.dolir.mo.gov/wc if you have any questions about your rights or benefits under the Workers’ Compensation Law. Keep a copy for your records. + WC-185 WC-185 (10-07) AI American LegalNet, Inc. www.FormsWorkflow.com