§ Form No. 8-C Worker's Compensation

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                      Signature of Attorney or Appellant
                                              Commission)

    (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 TYPE NAME AND BAR ENROLLMENT NUMBER OF
APPELLANT'S ATTORNEY 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____