DEPARTMENT or LABOR AND INDUSTRIAL RELATIONS DIVISION ImuRv NUMBER (Imam; DIVISION or COMPENSATION 12,077446 0. Box 55 Jeflemm (my, MD Amman CLAIM FOR COMPENSATION NOYE: This Iann mIm be commune II) unruly and mum: mm puma in mm In! ORIGINAL AMENDED INJURY CLAIM FUND ONLY SLIDMITAN ORIGINAL AND THAEE COPIES Please mad inslructions anare complerrng cm: 1mm. ITEM NUMBERIS) AMENDED EMPLOYEE INFORMATION I INJURED EMPLOYEES NAME INITIAL 0R 5 (ALSO INCLUDE ADDRESS) LAST FIRST MIDDLE NAME Benjamin STATE I 2 SOCIAL SECURITY NO 3, DATE OF ACCIDENY OR OCCUPATIONAL DISEASE TX 4. AVERAGE WEEKLY 5. TIME OF ACCIDENT 6. PLACE OF ACCIDENT (CW Zip] WAGE DAM SoulhwEsICIIy. McDonald MD Per m. 10,00 7 PARKS) 0F BODV INJURED Eyes. Iaoe, righl arm 5 DESCRIBE WHAT TNE EMPLOVEE WAS WING AND HOW THE INJURY OCCURRED In the soaps and Dawn 0! emplaymenI, me Emplayee was washing a (mile! wIIh an acid wand when he was sprayed qun ma am airecny resuIling in injury. Propel house was given EMPLOVER INFORMATION -- addl rIaI employers nzeu ID be llsIed on II yDu Med more space, anacn iddiliunil anaeIs, WHOM TNIS CLAIM Is FILED TRIS IS TNE EMPLOYER mass 'mE INJURY OR OCCUPATIONAL DISEASE OCCURRED FOR JOE WAGE BENEFITS LIST EMPLOYER SEPARATELV IN sex In EMPLOVER MAILING ADDRESS Slmmons Foods. Inc, 601 N. Hico Sly CITV Slloam STATE AR ZIP 600E 72761 EMPLOYER a MAILING ADDRESS cITv STAYE ZIP CODE EMPLOYER MAILING ADDRESS cm STATE ZIP CODE 10 ADDITIONAL STATEMENTS DIVISION USE ONLV RECEIVED Nov 1 9 2m ch Room DATE STAMP BE SURE To NEXT PAGE. WG-21 Iowa AI SECOND INJURY FUND CLAIM: IF YOU ARE NOT FILING AELAIM AGAINST THE SECOND INJURY FUND. PLEASE PROCEED TO BOX 13. H. ONLY CHECK APPROPRIATE BOXIES) IF YOU ARE FILINGA CLAIM AGAINST THE SECOND INJURY FUND FOR ANY OF THE FOLLOWING: PERMANENT PARTIAL DISABILITY [j CNINSDRED EMPLOYER MEDICAL AIDIDEATH BENEFITS PERMANENT TOTAL DISABILITY SECOND JOB WAGE LOSS 11A. IF YOU ARE FILING A CLAIM AGAINST THE SECOND INJURY FUND BASED UPON A FREE-EXISTING DISABILITY YOU NEED TO PROVIDE THE FOLLOWING INFORMATION. IF AVAIILAELE: DATE OF PREVIOUS OF BODY AFFECTED BY INJURWDISEASE PREVIOUS INJURWDISEASE SECOND JOB WAGE LOSS: 12. IF YOU ARE FILINGA CLAIM AGAINST THE SECOND INJURY FUND FOR SECOND JOB WAGE LOSS. PLEASE PROVIDE THE EMPLOYER NAME. MAILING ADDRESS. CITY. STATE, ZIP CODE. AND COUNTY FOR SECOND JOB WAGE LOSS IN BOX 10. DID INJURY RESULT IN YES NO 13A. DATE OF DEATH IF 1 IF DEATH OCCURRED. EMPLOYEES DEPENDENTS ISPOUSE. MINOR CHILDREN. OTHER PERSONS DEPENDENT ON 5 YOU NEED TO LIST DEPENDENTS IN ADDITION TO THESE LISTED BELOW. PLEASE ATTACH A SEPARATE SHEET. 14. NAME DATE OF BIRTH RELATTONSHIP TAAILINC ADDRESS CITY STATE ZIP CODE ITEA. NAME DATE OF BIRTH RELATIONSHIP MAILING ADDRESS CITY STATE ZIP CODE FMS. NAME DATE OP BIRTH RELATIONSHIP MAILING ADDRESS CITY STATE ZIP CODE CLAIM IS HEREBY MADE FOR ALL COMPENSATION AS PROVIDED IN THE MISSOURI WORKERS COMPENSATION LAW, RELATING TO INJURY (OR OF THE EMPLOYEE BY ACCIDENT ARISING OUT OF AND IN THE COURSE OF THE EMPLOYMENT. JURED EMPLOYEE OR CLAIMANT SIGNATURE 1E. EMPLOYEEICLAIMANT TELEPHONE NO. \ch ADM MDW SIGNATU TBA. ATTORNEY NAME (1'pr 0! pm? 185. GAR NUMBER MIDDSSI P. Mergen 35555 TS. ATTORNEY PHONE NLIMBER TSA. ATTORNEY FAX NUMBER 193. ATTORNEY E-MAIL ADDRESS (Optiona? {417'} 890-5700 {417) 890-8355 mmergen@hSIIBnSIBy.CDm 20. ATTORNEY MAILING ADDRESS 20A. CITY 203. STATE 20C. ZIP CODE 3275 E. Ridgeview Spring?GId MO 65804 LINES 15 SI 13 MUST BE SIGNED IN BLACK INK - NOT TYPED. (03-04] AI