Form No. 8-C. Worker's Compensation

 

 

NOTICE OF APPEAL

 

TO MISSOURI COURT OF APPEALS

 

__________________________ DISTRICT

 

BEFORE THE LABOR AND INDUSTRIAL

RELATIONS COMMISSION

STATE OF MISSOURI

 

 _____________________________________

)

 

 

)

 

Claimant.

)

 

 

)

Injury No. _______________________________

vs.

)

Appellate Court No. _______________________

 

)

 

 _____________________________________

)

 

 

)

 

Employer.

)

 

 

Notice is hereby given that _______________ appeals to the Missouri Court of Appeals _______________ District.

 

 _______________________________________

 _________________________________________

Date notice of Appeal filed (to be filled in by Secretary of Commission)

Signature of Attorney or Appellant

 

(The appellant(s) must file the original notice of appeal and one copy for the Appellate Court with, and pay the docket fee required by the court rule to, the secretary of the commission within the time specified by law. At the same time appellant must serve a copy of the notice of appeal on attorneys of record of all parties other than appellant(s), and on all parties not represented by an attorney. Proof of service shall be made on the original and copy to be filed with the commission.)

 

CASE INFORMATION

 

TYPE NAME AND BAR ENROLLMENT NUMBER OF APPELLANT'S ATTORNEY

TYPE NAME AND BAR ENROLLMENT NUMBER OF RESPONDENT'S ATTORNEY

 

* List additional respondents on page two of this form

 

 

 _______________________________________

 _________________________________________

 

 

Street __________________________________

Street ____________________________________

City ____________________________________

City ______________________________________

State ______________ Zip Code ____________

State ______________ Zip Code ______________

Telephone _______________________________

Telephone _________________________________

TYPE NAME OF APPELLANT

TYPE NAMES OF

 _______________________________________

Employee: _________________________________

Street __________________________________

Dependents: _______________________________

City ____________________________________

Employer: _________________________________

State ______________ Zip Code ____________

Insurer: ___________________________________

Date of Commission Award or Decision.

Date and County of Accident

 _______________________________________

 _________________________________________

(Attach copy of Commission Award or Decision)

 

Second Injury Fund Involved: YES ___ NO ___

 _________________________________________

 

 

 

DIRECTIONS TO COMMISSION

 

A copy of the notice of appeal and the docket fee shall be mailed forthwith to the clerk of the appellate court. The record on appeal shall be prepared and certified within such time as to enable timely filing by the appellant.

 

PROOF OF SERVICE

 

I have this day served a copy of this notice of appeal on each of the following persons at the address stated by _____________________________ (ordinary mail, certified mail, personal service):

 

___________ Signature of Attorney or Appellant

 

Date: __________, 20____