MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 INJURY NUMBER SUBSTITUTION OF COUNSEL , Employee vs. , Employer and , Insurer , Third Party Administrator SUBSTITUTION OF COUNSEL On behalf of the Employee Employer/Insurer Third Party Administrator ) ) ) ) ) ) ) ) ) ) ) ) ) ) - + Date of Accident/ Occupational Disease: COMES NOW, the undersigned attorneys and request substitution of counsel in the above case. Respectfully Submitted, Entering Firm/Attorney or Co-Counsel Signature Attorney Name Law Firm Address City, State, ZIP Phone No. Fax No. Bar No. Email Address Comments/Statements: Withdrawing Firm/Attorney or Co-Counsel Signature Attorney Name Law Firm Address City, State, ZIP Phone No. Fax No. Bar No. Email Address CERTIFICATE OF SERVICE I certify that a copy of this Substitution of Counsel was mailed or hand delivered to all parties of record, or if represented by an attorney, to their attorneys of record this day of , 20 . Attorney's Signature Attorney's Name (Printed) Address (if different than above) Bar No. Date DIVISION USE ONLY DATE STAMP Missouri Division of Workers' Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711 + WC-237 WC-237 (01-17) AI American LegalNet, Inc. www.FormsWorkFlow.com