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                                                                                    MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS                                                           P.O. Box 58 
                                                                                    REPORT OF INJURY                                                                        Jefferson City, MO 65102-0058 
                                                                                                                                                                                            (To complete form, 
                                                                                                                                                                                      see attached instructions) 
                                                         EMPLOYER  (NAME, ADDRESS, INCL ZIP CODE)         CARRIER ADMINISTRATOR CLAIM NUMBER                                       REPORT PURPOSE CODE 
                                                                                                                                                                                                 
                                                                                                          JURISDICTION                          JURISDICTION CLAIM NUMBER 
                                                                                                                                                               
                                                                                                          INSURED REPORT NUMBER 
                                                                                                                        
                            GENERAL                                                                       EMPLOYERS LOCATION ADDRESS  (IF DIFFERENT)                             LOCATION # 
                                                                                                                                                                                            
                                                         SIC CODE     EMPLOYER FEIN                                                                                              PHONE # 
                                                                                                                                                                                            
                                                         CARRIER  (NAME, ADDRESS & PHONE NO.)             POLICY PERIOD              CLAIMS ADMINISTRATOR  (NAME, ADDRESS & PHONE NO.) 
                                                                                                                               to                     
                                                                                                                              
                                                                                                          CHECK IF APPROPRIATE 
                                                                                                                   SELF INSURANCE 
        CARRIER                                          CARRIER FEIN                    INSURANCE POLICY NUMBER                                                                   ADMINISTRATOR FEIN 
                                       CLAIMS ADMIN                                                                                                                                              
                                                         AGENT NAME & CODE NUMBER 
                                                                    
                                                         NAME  (LAST, FIRST, MIDDLE)                             DATE OF BIRTH       SOCIAL SECURITY #             DATE HIRED               STATE OF HIRE 
                                                                                                                                                                                                       
                                                         ADDRESS (INCLUDE ZIP)                                   SEX                MARITAL STATUS               OCCUPATION JOB TITLE 
                                                                                                                    MALE              UNMARRIED                             
                                                                                                                    FEMALE                   SINGLE   DIVORCED   EMPLOYMENT STATUS 
                                                                                                                    UNKNOWN           MARRIED                               
                            EMPLOYEE                     PHONE #                                   # OF DEPENDENTS                    SEPARATED                  NCCI CLASS CODE 
                                                                                                                                      UNKNOWN                               
                                                         RATE 
                       WAGE                                                    PER        DAY        MONTH              # OF DAYS WORKED/WEEK         FULL PAY FOR DAY OF INJURY?                       YES     NO 
                                                                                          WEEK       OTHER                                            DID SALARY CONTINUE?                              YES     NO 
                                                         TIME EMPLOYEE BEGAN WORK     AM      DATE OF INJURY / ILLNESS  TIME OF OCCURRENCE       AM LAST WORK DATE DATE EMPLOYER NOTIFIED  DATE DISABILITY BEGAN 
                                                                                      PM                                                         PM                                                         
                                                         CONTACT NAME PHONE NUMBER                           TYPE OF INJURY ILLNESS                              PART OF BODY AFFECTED 
                                                                                                                                                                            
                                                         DID INJURY ILLNESS EXPOSURE OCCUR                   TYPE OF INJURY/ILLNESS CODE                         PART OF BODY AFFECTED CODE 
                                                         ON EMPLOYER’S PREMISES?      YES       NO                                                                          
                                                         ZIP CODE OF THE LOCATION WHERE THE ACCIDENT OR ILLNESS EXPOSURE           ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR 
                                                         OCCURRED                                                                  ILLNESS EXPOSURE OCCURRED 
                                                                                                                                              
                                                         SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR        WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE 
                                                         ILLNESS EXPOSURE OCCURRED                                                 OCCURRED 
                            OCCURRENCE 
                                                                                                                                              
                                                         HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR          CAUSE OF INJURY CODE 
                                                         SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL. 
                                                                                                                                                                                                    
                                                         DATE RETURN TO WORK                      IF FATAL, GIVE DATE OF DEATH              WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?               YES     NO 
                                                                                                                                            WERE THEY USED?                                             YES     NO 
                                                         PHYSICIAN HEALTH CARE PROVIDER  (NAME & ADDRESS)        HOSPITAL      (NAME & ADDRESS)                    INITIAL TREATMENT 
                                                                                                                                                                    0 - NO MEDICAL TREATMENT 
                                                                                                                                                                    1 – MINOR: BY EMPLOYER 
                TREAT-                              MENT                                                                                                            2 – MINOR CLINIC HOSPITAL 
                                                         WITNESS  (NAME & PHONE #)                                                                                  3 – EMERGENCY CASE 
                                                                                                                                                                    4 – HOSPITALIZED  >  24 HOURS 
                                                                                                                                                                    5 – FUTURE MAJ. MED. LOST TIME ANTICIPATED 
                                                         DATE ADMINISTRATOR NOTIFIED  DATE PREPARED          PREPARER’S NAME & TITLE                                                   PHONE NUMBER 
                            OTHERS                                                                                                                                                                  
 
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NOTE > This form constitutes the detailed report of injury required by §287.380, RSMo Cum.
Supp. (2005) and rules applicable thereto. An injury that requires immediate first aid, which does
not result in further medical treatment or lost time from work, need not be reported to the
Division. Employers should report all injuries to their workers’ compensation insurance carrier or
third-party administrator (TPA) within five days of the date of the injury or within five days of the
date on which the injury was reported to the employer by the employee, whichever is later. See
§287.380, RSMo. If the employer has been granted self-insurance authority by the Division
pursuant to §287.280, RSMo, and rules applicable thereto, please report all injuries to your TPA
or Service Company to enable them to file this report with the Division.

PRINT QUALITY > All reports of injury and supporting documents received by the Division will
be processed electronically. All forms submitted to the Division MUST be of clear and legible
quality. Handwritten forms will not be accepted. Computer generated forms shall use a minimum
type size of 10 points. All documents not meeting the above criteria will be returned.

TO BE ANSWERED ONLY IN CASE OF DEATH
DATE OF DEATH

EMPLOYEE’S DEPENDENTS
NAME OF RELATION TO ADDRESS OF DEPENDENT
DEPENDENT EMPLOYEE ADDRESS CITY STATE ZIP CODE

Missouri Division of Workers’ Compensation is an equal opportunity employer/program.
Auxiliary aids and services are available upon request to individuals with disabilities.
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                                       Data Element Dictionary for Hard Copy Report of Injury  

                                                                                                                                                     Mandatory 
Data Element    IAIABC Data Definition                                         Missouri Notes 
                                                                                                                                                     Field 
Employer (Name  The name of the employer where the employee was                This is the name the employer does business under followed by         M 
& Address)      employed at the time of the injury.                            the FULL address including mailing address, city, state and zip 
                                                                               code.  
Industry Code   The code which represents the nature of the employer’s         This is the Standard Industrial Classification Code for the           M 
                business which is contained in the North American Industry     employer. SIC/NAICS codes can be found at  
                Classification System Manual published by the Federal 
                                                                               www.census.gov/epcd/www/naics.html 
                Office of Management and Budget. 
                 
                See implementation note below: 
                The industry code selected should represent the primary 
                nature of the employer’s business. If the employer is 
                assigned multiple industry codes, use the code that relates 
                to the specific business operation for which the employee 
                was employed at the time of the injury. The data element 
                may contain an SIC code or NAICS Code. SIC code will be 
                identified with the characters ‘SC’ as the last two characters 
                of the data element. If SC is not present, the code is 
                presumed to be NAICS. 
Employer FEIN   The FEIN of the employer where the employee was                Must be the primary FEIN for the Employer listed above.               M 
                employed at the time of the injury. 
Report Purpose  Defines the specific purpose of the report being filed with the  The Report of Injury that the employer is required to file with the M 
Code (RPC)      state of Missouri.                                             Division of Workers’ Compensation (Division) through the 
                                                                               insurance carrier or third party administrator (TPA). 
                00 = Original FROI  
                02=Change  
                CO=Correction 
                AQ=Acquired Report of Injury 
                AU=Acquired Unallocated Report of Injury  
Claims          Identifies a specific claim within a claim administrator’s     Number used by the organization adjusting the claim (insurance        M 
Administrator’s claims processing system.                                      company, third party administrator, etc.). 
Number  
Jurisdiction    The governing body or territory whose statute applies.         This must always be Missouri.                                         M 

Jurisdiction                                                                   The injury number assigned by the Division upon receipt of the         
Claim Number                                                                   First Report of Injury with all mandatory information provided. The 
                                                                               reporting entity is to leave this field blank. 
                                                                                                                                           WC-1-EDI-3 (04-14)  AI

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                                                                                                                                                             Mandatory 
Data Element      IAIABC Data Definition                                           Missouri Notes 
                                                                                                                                                             Field 
Insured Report    A number used by the insured to identify a specific claim.                                                                                 O 
Number 
Employer’s        List the physical address of where the employee sustained                                                                                  O 
Location          the accident or illness if that location is different from where 
Address           the employer wishes to have correspondence sent. 
Insured Location  A code defined by the insurer/employer, which is used to                                                                                   O 
Number            identify the employer’s location of the accident. 
Phone Number      List a phone number of the employer location where the                                                                                     O 
                  employee worked at the time of the accident. 
Carrier (insurer) The name and mailing address of the carrier or self-insured      If the employer is individually self-insured, the individual self-        M 
Name & Address  entity assuming the employer’s financial responsibility for        insured employer’s name and mailing address would be indicated 
                  the workers’ compensation claim.                                 in this field. The FEIN and Name must match. 
                                                                                   If the employer is self-insured by a trust, the trust’s name 
                                                                                   would be submitted in this field. 
                                                                                   Please see Special Notes #3 
Carrier (insurer) The FEIN of the carrier or self-insured assuming the                                                                                       M 
FEIN Number       employer’s financial responsibility for the workers’ 
                  compensation claim(s). 
Carrier Policy    The number assigned to the contract/policy for the employer  A number assigned by the insurance company, (Not a number                     M 
Number            or association group.                                            assigned by a TPA) for the specific workers’ compensation 
                                                                                                                                                              
                                                                                   policy for that employer. 
                   
                                                                                   Not a required field for Division approved self-insureds. 
Policy Period     List the effective and expiration dates of the contract/policy.   The date that the policy became effective and the date the policy        M 
                                                                                   expires or is no longer in effect. 
                   
                                                                                   No date is required in this field if the injury falls within the Division 
                                                                                   approved self-insurer’s self-insurance period. 
Self-Insured      An indicator that identifies the employer as one who is          Condition – Must indicate Y(Yes) ONLY for an individual employer          C 
Indicator         authorized by the state of Missouri to retain the risks arising  or a member of a self-insured trust authorized by the Missouri 
                  from their operations and bears the financial responsibility.    Division of Workers’ Compensation to self-insure under § 287.280, 
                  Y=Yes,  N=No                                                     RSMo. It does not include uninsured employers or employers under 
                                                                                   deductible insurance policies.  
                                                                                    
Claim             The name and mailing address of the Third Party                  Name and mailing address of the Third Party Administrator (TPA),          C 
Administrator     Administrator (TPA), independent administrator, contracted       independent adjuster, contracted to adjust the claim and phone 
(TPA) Name &      to adjust the claim on behalf of the carrier or self-insured.    number of the office adjusting the claim. If there is not a TPA, 
Address                                                                            independent adjuster/administrator, contracted to adjust the claim 
                                                                                   please leave blank. 
                                                                                                                                                    WC-1-EDI-4 (04-14)  AI

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Mandatory
Data Element IAIABC Data Definition Missouri Notes
Field
Claim The FEIN of the Third Party Administrator (TPA), FEIN number for the company hired as a TPA. Note: If there is no C
Administrator independent adjuster/administrator, contracted to adjust the Third Party Administrator, please leave blank.
(TPA) FEIN claim on behalf of the carrier or self-insured.
Number
Agent Name & List the name and code number of the carrier or claim O
Code Number administrator agent who administers the workers’
compensation claims for the employer.
Employee Name The injured worker’s legally recognized name which is used Name to include last, first and middle initial. M
on legal documents, employment, Social Security, banking,
records, etc.
Employee Date The date the injured worker was born. Must be a valid date. M
of Birth
Social Security A number assigned by the Social Security Administration If a SSN is not available please call 573-526-3542. M
Number used to identify the employee.
Date of Hire The date the injured worker began his/her employment with Must be valid date. O
the employer under which the claim is being filed. If there
have been multiple periods of employment, this would be
the beginning date of the current employment period.
State of Hire List the state where the employer hired the employee. O

Employee The mailing address used by the injured worker. The address should not be listed as unknown. Please include the M
Address last known address provided by the employee that is on file with
the employer.
Employee Phone A telephone number where the injured worker can be This is an optional field, although if the employer or insurance O
reached. company has this information, please report it to the Division.
This will improve communication between the parties. This will be
a numeric field only 5736367777.
Gender Code The code which indicates the sex of the employee. M
Gender of employee F=Female M=Male U=Unknown
Number of The number of dependents as defined by the administrating Spouse, minor children or others if known. Required if date of C
Dependents jurisdiction. death is entered. Numeric field 0-9.
Marital Status The code, which indicates the marital status of the O
Code employee.
U = Widowed, divorced, single, unmarried, M = Married,
S = Separated, K = Unknown

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                                                                                                                                                      Mandatory 
Data Element     IAIABC Data Definition                                       Missouri Notes 
                                                                                                                                                      Field 
Occupational/    Identifies the primary occupation of the employee at the time                                                                        O 
Job Title or     of the accident or injurious exposure. 
Description 
Employment       Indicate the employee’s primary work code status at the                                                                              O 
Status Code      time of the injury with the covered employer. 
NCCI Class       A code, which, corresponds to the primary occupation in      MO uses NCCI codes.                                                     M 
Code             which the employee was engaged at the time of the 
                 accident/injury or injurious exposure. 
Wage             The reported employee’s pre-injury wage for the wage         “Gross Wages” includes, in addition to money paid by the                M 
                 period.                                                      employer for services rendered by the employee, the reasonable 
                                                                              value of board, rent, housing, lodging or similar advance by the 
                                                                              employer, except if it continues to be provided to the employee for 
                 Implementation Note:                                         the period of disability, it is not included in calculating the average 
                 This amount may include commission, piecework earnings,      weekly wage. “Wages” also includes gratuity received in the 
                 and other forms of income converted to a normal scheduled    course of employment from individuals other than the employer 
                 work week, plus the estimated value of lodging, food,        that are reported for income tax purposes. “Wages” does not 
                 laundry and other payments in kind; and concurrent           include fringe benefits such as retirement, pension, health and 
                 employment earnings, as prejurisdictional requirement.       welfare, life insurance, training, Social Security or other employee 
                                                                              or dependent benefit plan provided by the employer. 
                  
                                                                              Please See Special Notes #1  
Wage Period      A code indicating the time period during which the wage was  Please use the weekly wage rate paid to the employee.                   M 
                 earned. 
Number of Days  The number of the employee’s regularly scheduled                                                                                      O 
Worked           workdays per week. 
Full Wages Paid  Indicates whether full wages for the date of the                                                                                     O 
for the Date of  accident/injury or illness were paid by the employer. 
Injury Indicator 
Salary           The employer has paid or is paying the employee’s salary in  Did the employer continue to pay salary to the employee after the       O 
Continued        lieu of compensation during an absence caused by a work-     injury?   N=No   Y=Yes 
Indicator        related injury. 
Time Employee    Time at which the employee began work on the day of the                                                                              O 
Began Work       accident/injury or illness. 
Date of          For traumatic injury, the date on which the accident         Date that injury/illness occurred or became known to employee;          M 
Injury/Illness   occurred. For occupational disease or cumulative injury, the  whichever is later. 
                 date of injury is the date of last injurious exposure to the 
                 cause or substance creating the condition, unless otherwise 
                 defined by statute. 

                                                                                                                                              WC-1-EDI-6 (04-14)  AI

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                                                                                                                                                      Mandatory 
Data Element    IAIABC Data Definition                                           Missouri Notes 
                                                                                                                                                      Field 
Time of         The time at which the accident occurred.                         To the extent that the time of the occurrence of the accident/injury O 
Occurrence                                                                       is available, you should provide it to the Division. Please indicate 
                                                                                 a.m. or p.m. 
Date Last Day   The last paid workday prior to the initial date of disability as Must be valid date.                                                  O 
Worked          defined by jurisdiction. 
Date Employer   The date that the injury was reported to a representative of                                                                          M 
Notified        the employer. 
Date Disability The first day on which the employee originally lost time from    Date of disability must be greater than Date of Injury.              C 
Began           work due to the occupational injury or disease or as 
                                                                                 First date employee starts losing time from work after the date of 
                otherwise defined by jurisdiction. 
                                                                                 injury. This is the day after the date of injury or the first day of 
                                                                                 work missed, if later. The three-day waiting period is calculated 
                                                                                 from the first date of lost time and the lost time does not need to 
                                                                                 be consecutive days. 
                                                                                 Please See Special Note #2 
Contact Name &  List the name and phone number for a representative of the                                                                            C 
Phone Number    employer. 
Type of         List the type of injury/illness sustained by the employee.                                                                            O 
Injury/Illness 
Part of Body    List the part of body to which the employee sustained injury.                                                                         O 
Affected 
Employer        An indicator to denote whether the accident occurred at the      If the injury/illness occurred on the employer’s property indicate   M 
Premises        employer’s address provided.                                     “YES.” If it occurred elsewhere indicate “NO.” 
Indicator 
Type of         The code, which corresponds to the nature of the injury          Choose from the list of code numbers, which corresponds with the     M 
Injury/Illness  sustained by the employee.                                       nature of the injury. 
Code  
                                                                                 A list of codes with description of each code is available at 
                                                                                 www.wcio.org/Document%20Library/InjuryDescriptionTablePage.
                                                                                 aspx Please See Special Notes #2 
Part of Body    The code, which corresponds to the part of the body to           Choose from the list of code numbers, which corresponds with         M 
Affected Code   which the employee sustained injury.                             the part of body injured. A list of codes with a description of each 
                                                                                 code is available at 
                                                                                 www.wcio.org/Document%20Library/InjuryDescriptionTablePage.
                                                                                 aspx 

                                                                                                                                                      WC-1-EDI-7 (04-14)  AI

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                                                                                                                                                     Mandatory 
Data Element      IAIABC Data Definition                                         Missouri Notes 
                                                                                                                                                     Field 
Zip Code of the   The zip (postal code) that corresponds to the location where  The code is required to assist with docket setting if needed.        M 
Location Where    the injury occurred. 
                                                                                                                                                      
Accident or 
Illness Exposure 
Occurred 
All Equipment     List all the equipment; materials or chemicals the employee                                                                        O 
Using             was using at the time of the accident/injury or illness 
                  exposure occurred. 
Specific Activity Describe the specific activity that the employee was doing at                                                                      O 
Engaged In        the time the accident/injury or illness exposure occurred. 
Work Process      Describe the work process the employee was doing when                                                                              O 
Engaged In        the accident/injury or illness exposure occurred. 
How the Injury or  A free form description of how the accident occurred and the  Describe how the injury/illness occurred. Please include the        M 
Illness Occurred  resulting injuries.                                            events that led to the injury/illness and any objects or substances 
                                                                                 that directly injured the employee or made the employee ill. 
                                                                                 Maximum of 150 characters, including spaces. 
                                                                                 For example: Employee was on ladder putting away product, fell 
                                                                                 on chemical barrel breaking lower arm; arm lacerations; exposed 
                                                                                 to chemical liquid and fumes (141 characters). 
Cause of Injury   The code which corresponds to the cause of injury.             Choose from the list of code numbers, which corresponds with        M 
Code                                                                             the cause of the injury. A list of codes with a description of each 
                                                                                 code is available at 
                                                                                 www.wcio.org/Document%20Library/InjuryDescriptionTablePage.
                                                                                 aspx (Struck by, fell, auto accident, exposure, etc.) 
Date Returned to  The first date on which the employee returned to work          Must be a valid date. Must be entered if employee lost days of      C 
Work              following the injury.                                          work and returned to work before first report of injury is filed. 
                   
Employee Date     The date the injured worker died.                              Must be a valid date.                                               C 
of Death 
Safeguards        Indicate whether safeguards or safety equipment was                                                                                O 
                  provided by checking “Yes” or “No.” 
Were They Used  Indicate whether the safeguards or safety equipment was                                                                              O 
                  used by the employee by checking “Yes” or “No.” 
Physician/Health  List the name and address of the physician or health care                                                                          O 
Care Provider     provider who provided initial medical treatment to the injured 
                  employee after the accident/injury or illness. 

                                                                                                                                                   WC-1-EDI-8 (04-14)  AI

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                                                                                                                                                    Mandatory 
Data Element    IAIABC Data Definition                                      Missouri Notes 
                                                                                                                                                    Field 
 Hospital       List the name and address of the hospital where the                                                                                 O 
                employee received initial medical treatment. 
 Initial Treatment  A code used to identify the extent of medical treatment First Aid includes the administration of immediate and temporary        M 
                received by the employee immediately following the          medical aid to the employee that a lay person may provide, such 
                accident.                                                   as the application of Band-Aid to treat a minor scratch or the 
                                                                            removal of a splinter that would not result in the need for a referral 
                0= No medical treatment 
                                                                            to a doctor or other health care professional for additional medical 
                1= Minor on-site remedies by employer medical staff         treatment or would not result in further lost-time from work. The 
                                                                            on-site company nurse or physician may be the individual that 
                2= Minor clinic/hospital medical remedies and diagnostic    provides the first aid. If the company nurse or physician provides 
                  testing 
                                                                            service beyond first aid, then the injury must be reported even if 
                3= Emergency evaluation, diagnostic testing, and medical    the treatment occurs on-site. 
                  procedures                                                Please see Special Notes #2  
                4= Hospitalization > 24 hours 
                                                                             
                5= Future major medical/lost time anticipated 
 Witness        List the name and address of all witnesses who were                                                                                 O 
                present when the employee sustained the accident/injury or 
                illness. 
 Date Reported to  The date the claim administrator who is processing the claim                                                                     M 
 Claims         received notice of the loss or occurrence. 
 Administrator 
 Date Prepared  List the date that the representative for the claims                                                                                O 
                administrator prepared this report of injury. 
 Preparer’s Name  List the name and title of the claims administrator’s                                                                             C 
 and Title      representative who prepared this report of injury. 
 Phone Number   List the phone number of the representative preparing this                                                                          C 
                report of injury. 
 
 M – Mandatory – Cases missing mandatory information will NOT be accepted by the Missouri Division of Workers’ Compensation system. 
 C – Conditional – Data Elements with Conditional fields indicate a value is required based on another Data Element or pre-existing condition. 
                  Examples:  When a death case is reported then the death date would be required. 
                                If the employee has returned to work prior to the report being filed, the date of return to work would be entered.  
 O – Optional – Data Elements identified as Optional may be entered but are not required. 

                                                                                                                                                    WC-1-EDI-9 (04-14)  AI

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Special Notes
1) Wage Instructions
A) Missouri Notes: Report the wage information as the average weekly wage (AWW) of the employee. These rules apply for calculating the average weekly
wage.
1) If the employee’s wage is fixed by the year, the AWW is the yearly wage divided by 52;
2) If the employee’s wage is fixed by the month, the AWW is the monthly wage multiplied by 12 and divided by 52;
3) If the employee’s wage is fixed by the week, that amount is the AWW;
4) If the employee’s wages are fixed by the day, hour or output, the numerator is the actual gross wages earned by the employee in the last thirteen
calendar weeks immediately preceding the week in which the injury occurred; and the denominator is 13 to calculate the AWW.

i) The formula is: Actual gross wages earned in prior 13 weeks/13=AWW. For example, the employee’s hourly wage is $9.00/hour. The overtime
rate is $13.50/hour. The employee works 40 hours per week at $9.00 an hour plus occasional overtime. Employee worked overtime of 44
hours in the 13-week period immediately preceding the week of the injury. The employer has employed the employee for 2 years.
The gross wages are $9.00 X 40 hours X 13 weeks = $4,680. You also need to include the overtime 44 hours. Therefore, $13.50 X 44 hours =
$594. The total wages are $4,680 plus $594 = $5,274. The AWW is $5,274/13=$405.69.
ii) If the employee misses nonconsecutive workdays during the 13-week period in multiples of 5 those days shall be subtracted from the
denominator. For example: if the employee misses 5 days, one week is subtracted from 13 and the denominator becomes 12; if the employee
misses 10 days, two weeks are subtracted from 13 and the denominator becomes 11; and so on.
iii) Partial weeks of time missed by the employee do not count to change the denominator. For example: if the employee misses 4 days, the
denominator is 13; if the employee misses 6 days, one week is subtracted from 13 and the denominator becomes 12; and so on.
iv) If the employee works less than 13 weeks but more than 2 weeks, the AWW is the same formula with the numerator as the gross wages
calculated for the number of weeks of employment and the denominator is the number of weeks of employment. For example, the employee
worked for the employer 8 weeks prior to the week of the injury. The employee was paid $9.00 per hour and worked 40 hours per week. The
employee worked 13 hours of overtime. The overtime rate is $13.50. The gross wages are $9.00 X 40 hours X 8 weeks plus $13.50 X 13
hours = $3,055.50. The AWW is $3,055.50/8=$381.94.
5) If the employee works less than two weeks the AWW shall be equivalent to the AWW for the same or similar employment. However, if the employer
has agreed to a certain hourly wage, then the hourly wage agreed upon multiplied by the number of weekly hours scheduled shall be the
employee’s AWW.
B) When the Date Returned to Work is more than three days from the Date Disability Began, the workers’ compensation case will be considered an
indemnity case. You will receive a request for the cost of medical treatment, the date returned to work, and the total amount of temporary total
disability benefits paid to the employee.
C) When Initial Treatment Code is reported as equal to 00, 01 or 02, the case will be considered as a medical only case. If the time period between the Date
Disability Began and the Date Returned to Work is three days or less, the case will be classified as a medical only case. You will receive a request for the
cost of medical treatment and the date returned to work, if not supplied. After all required information has been filed and there is no further activity on a case
for six months, the case may be administratively closed. When the Initial Treatment Code is reported as equal to 03, 04 or 05, the case will be considered
as an indemnity case. You will receive a request for the cost of medical treatment, the date returned to work, and the total amount of temporary total
disability benefits paid to the employee.

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Wage Instructions (Continued)
D) The following are examples of First Aid treatment:
a) Use of non-prescription medication at non-prescription strength.
b) Cleaning, flushing or soaking wounds on the surface of the skin.
c) Using wound coverings such as bandages, Band-Aids, gauze pads, etc. or using butterfly bandages or Steri-Strips. (Other wound closing
devises such as sutures, staples, glues, etc. are considered medical treatment.)
d) Use of any non-rigid means of support such as an elastic bandage, wrap, or non-rigid belt. (The use of devices with rigid stays or other systems
designed to immobilize body parts is considered medical treatment.)
e) Use of temporary immobilization devices (e.g., splints, slings, neck collars, etc.) while transporting an accident victim.
f) Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs, or other simple means.
g) Use of finger guards.
h) Drinking of fluids for relief of heat stress.

2) Initial Treatment Code, Date Disability Began and Date Returned to Work:
A) When Initial Treatment Code is reported as 00, 01 or 02, the case will be considered a medical only case. If the time period between the Date
Disability Began and the Date Returned to Work is three days or less, the case will be classified as a medical only case. You will receive a request
for the cost of medical treatment and the date returned to work, if not supplied. After all required information has been filed and there is no further
activity on a case for six months, the case may be administratively closed.
B) When the Initial Treatment Code is reported as 03, 04 or 05, the workers’ compensation case will be considered an indemnity case. You will
receive a request for the cost of medical treatment, the date returned to work, and the total amount of temporary total disability benefits paid to the
employee.
1) When the Date Returned to Work is more than three days from the Date Disability Began, the workers’ compensation case will be
considered an indemnity case. The three-day waiting period is calculated from the first date of lost time and the lost time does not need to
be consecutive days. You will receive a request for the cost of medical treatment, the date returned to work, and the total amount of
temporary total disability benefits paid to the employee.

3) Mesothelioma Liability: The Missouri Legislature made several changes to the Workers’ Compensation Law effective January 1, 2014. Pursuant to
§287.200.4 RSMo employers may elect to accept mesothelioma liability in one of the following ways:
a. Insuring their liability by purchasing a workers’ compensation policy;
b. Meeting the requirements of the Division of Workers’ Compensation to qualify as a self-insurer;
c. Joining a Group Insurance Pool that complies with §287.223. (An employer may become a member of the Missouri Mesothelioma Risk
Management Fund);
d. Rejecting mesothelioma liability under the Missouri Workers’ Compensation Law.
Please note that if an employer has rejected mesothelioma liability coverage under the Workers’ Compensation Law, the exclusive remedy provision of the
Workers’ Compensation Law §287.120 RSMo does not apply.

4) Occupational diseases: Occupational diseases due to toxic exposure have been defined in SB1 effective January 1, 2014. The “occupational diseases due to
toxic exposure” includes the following: asbestosis, berylliosis, coal worker’s pneumoconiosis, bronchiolitis obliterans, silicosis, silicotuberculosis, manganism, acute
myelogenous leukemia and myelodysplastic syndrome. The reporting requirements relating to other occupational diseases such as carpal tunnel syndrome, etc.
remains the same.
WC-1-EDI-11 (04-14) AI

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