MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS’ COMPENSATION 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 REQUEST FOR VOLUNTARY CONFERENCE + 1. INJURY NUMBER 2. Date of Injury Note: This form must be completed in its entirety and must be typed or hand printed in black ink. Please submit this form to the appropriate adjudication office. 3. Case Venue 4. Employee 5. Address of Employee 6. Employee’s Telephone No. 7. Attorney for Employee 8. Address of Employee’s Attorney 9. Employee’s Attorney Telephone No. 10. Attorney for Employer/Insurer 11. Address of Employer/Insurer Attorney 12. Employer/Insurer Attorney’s Telephone No. 13. Insurance Company and/or Third Party Administrator 14. Address of Insurance Company or Third Party Administrator, if known 15. Party Requesting the Conference 16. Please explain why you want a conference: An administrative law judge cannot act as an attorney for any party or give any specific legal advice to any party regarding the case. An administrative law judge shall approve a settlement agreement as long as: • The settlement is not the result of undue influence or fraud; • The employee fully understands his or her rights and benefits; • The employee voluntarily agrees to accept the terms of the agreement; and • The settlement is in accordance with the rights of the parties. DIVISION USE ONLY COMPLETED BY DIVISION OF WORKERS’ COMPENSATION Approved ______________________ 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-182 WC-182 (11-07) AI American LegalNet, Inc. www.FormsWorkflow.com