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Missouri Form Center -

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Form

Description

wc-1.pdf Report of Injury
wc-2.pdf Notice of Commencement / Termination of Compensation
MODOL-4474.pdf First Report of Occupational Fatality Missouri Census of Fatal Occupational Injuries
wc-9.pdf Medical Treatment Form
wc-21.pdf Claim for Compensation - claim for Workers' Compensation for injuries occurring prior to January 1, 2014.
wc-21a.pdf Claim For Compensation - claim for Workers' Compensation for injuries occurring on or after January 1, 2014 - based upon the revisions to the Workers' Compensation Law made by Senate Bill 1.
wc-22.pdf Answer to Claim For Compensation - for injuries occurring prior to January 1, 2014
wc-22a.pdf Answer to Claim For Compensation - for injuries occurring on or after January 1, 2014 (Includes Instructions)
wc-25.pdf Workers' Compensation Subpoena
wc-25-a.pdf Workers' Compensation Subpoena Duces Tecum
wc-25-b.pdf Workers' Compensation Subpoena For Deposition
wc-25-c.pdf Workers' Compensation Subpoena Duces Tecum For Deposition
wc-43.pdf Authorization to Inspect and/or Copy Medical Records
wc-81.pdf Application for Authority to Self-Insure
wc-81-a.pdf Application for Group Self-Insurance
wc-81-b.pdf Application for Membership
wc-82-a.pdf Guaranty to Satisfy Compensation Claims under Workers' Compensation Law of Missouri
wc-82-b.pdf Bond of Employer Carrying His Own Risk
wc-82-e.pdf Escrow Agreement
wc-83.pdf Self-Insurer's Statement of Outstanding Losses
wc-84.pdf Self-Insurer's Payroll Report
wc-85.pdf Self-Insurer's Annual Financial Statement
wc-86.pdf Self-Insurer's Report of Compensation Payments
4466.pdf BROCHURE - Resource Guide for Employers
wc-101.pdf BROCHURE - Facts for Injured Workers
wc-101-s.pdf BROCHURE - Facts for Injured Workers (Spanish)
wc-106.pdf POSTER - Workers' Compensation - This poster prints out on two sheets of paper (8.5 x 11) that can then be taped together and used as the poster.
wc-106-lg.pdf POSTER - Workers' Compensation - This poster can print out on one sheet of paper (11 x 17).
wc-106-sp.pdf POSTER - Workers' Compensation - This poster prints out on two sheets of paper (8.5 x 11) that can then be taped together and used as the poster. (Spanish)
wc-106sp-lg.pdf POSTER - Workers' Compensation - This poster can print out on one sheet of paper (11 x 17).( Spanish)
wc-107.pdf BROCHURE - Dispute Management for Injured Workers and Employers
wc-110.pdf Disability Schedule and Benefit Limits
wc-116.pdf Appeal Rights and Procedures in Workers compensation
wc-120.pdf BROCHURE - Second Injury Fund Surcharge
wc-121.pdf Statement of Specific and Aggregate Excess Insurance Coverage
wc-124.pdf BROCHURE - WC-124 Self-Insuring Workers' Compensation Liability Through Trusts
wc-126.pdf Authorization to Release Information (and instructions)
wc-127.pdf Proposed Rates for Workers' Compensation Group Self-Insurance
wc-128.pdf Checklist for Individual Self Insurance Applications
wc-129.pdf Self-Insured Trust Safety Program Initial Certification Procedures
wc-130.pdf Auditing Procedures for Applicants for Individual Self-Insurance
wc-131.pdf Individual Self-Insured Employer Information
wc-132.pdf Electronic Fund Transfer Enrollment Form
wc-133.pdf Electronic Data Distribution Trading Partner Profile (Receiver's Specifications)
wc-250.pdf Electronic Partnering/Confidentiality Agreement
wc-134.pdf Affidavit of Exemption for Workers' Compensation Insurance
wc-135.pdf 2016 Trust Self-Insurance Annual Report (WC-135)
wc-138.pdf Employee's Application for Religious Exception
wc-138-3.pdf Employee's Religious Exception Affidavit and Waiver
wc-138-5.pdf Employer's Affidavit for Religious Exception
wc-138-7.pdf Religious Exception Application and Affidavit Instructions
wc-138-a.pdf Religious Exemption Information
wc-182.pdf Request for Conference
wc-183.pdf Request for Pre-Hearing
wc-184.pdf Request for Mediation
wc-185.pdf Request for Hardship Hearing
wc-186.pdf Request for Hearing - Final Award
wc-194.pdf Request by a Health Care Provider for Case Status Information to file a Medical Fee Dispute Application
wc-198.pdf Answer to Application for Payment of Additional Medical Fees
wc-199.pdf Answer to Application for Direct Payment
wc-200.pdf Entry of Appearance
wc-201.pdf Request for Award on Undisputed Facts in Regards to Application for Direct Payment
wc-202.pdf Health Care Provider's Response to Request for Reward on Undisputed Facts in Regard to Application for Direct Payment
wc-214.pdf Application for Administrative Ruling
wc-235.pdf Entry of Appearance
wc-236.pdf Motion for Leave to Withdraw
wc-237.pdf Substitution of Counsel
wc-239.pdf Group Application Check List
wc-240.pdf Affidavit of Zero Reporting, Commercial Users Only
wc-241.pdf Physician's Report on Eye Injuries
wc-249.pdf Irrevocable Letter of Credit
wc-249-3.pdf Authorization to Release Confidential Information
wc-258.pdf Non-Compliance Referral Form
wc-265.pdf Surplus Distribution Request
wc-270.pdf Group Trust Member Information Update
wc-280.pdf Report Your Workplace Injury/Occupational Disease or Repetitive Trauma Injury
wc-281.pdf Joint Motion for Change of Venue
wc-297.pdf Request for Award on Undisputed Facts in Regard to Application for Payment of Additional Reimbursement of Medical Fees
wc-303.pdf Claimant Authorization To Disclose Workers' Compensation Records
wc-g-11.pdf Stipulation for Compromise Settlement
wcr-1a.pdf Physician's Rehabilitation Information Sheet
wcr-4a.pdf Verification of Rehabilitation Treatment
wcr-5a.pdf Bi-Weekly Report on Physical Rehabilitation
wcr-6.pdf Report of Serious Injury Referral Form
wcr-7.pdf Eligibility Guidelines for Second Injury Rehab Benefits
wcr-8.pdf Request for Certification
wc-md-01.pdf Application for Direct Payment
wc-md-02.pdf Payment of Additional Reimbursements of Medical Fees
wc-md-03.pdf Application for Evidentiary Hearing
wc-md-05.pdf Request for Dismissal of Application for Payment of Additional Reimbursements of Medical Fees
wc-md-10.pdf Request for Dismissal of Application for Direct Payment
wct-1.pdf Application for Tort Victims Compensation
wct-2.pdf Questions and Affidavit Regarding Benefit Sources and Payments -
wct-3.pdf Questions and Affidavit Regarding Lost Income
wct-4.pdf Questions and Affidavit Regarding Waiver of Final Judgement Requirement
wct-5.pdf Questions and Affidavit Regarding Due Diligence in Enforcing the Judgement
wct-6.pdf Questions and Affidavit Regarding Completeness of Medical Information Submitted
812-1321.pdf Application for Crime Victims' Compensation
indemgp.pdf Indemnity Agreement or Trust Agreement
moic-2567.pdf Application for Review to the Labor and Industrial Relations Commission
moic-2568.pdf Crime Victim Petition for Review to the LIRC
wclod-1.pdf Claim for Compensation for Line of Duty Compensation Benefits
namechngcklist.pdf Name and Address Change Form for Self-Insured Trusts