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Publications and Forms

Request for Dismissal of Application for Payment of Additional Reimbursement of Medical Fees (WC-MD-05)

A form for use by a health care provider requesting the dismissal of an application for payment of additional reimbursement of medical fees in a workers’ compensation “reasonableness” medical fee dispute.

Request for Hearing-Final Award (WC-186)

Request to DWC for a final award hearing regarding workers compensation claim.

Request for Hearing-Hardship or Section 287.203 RSMo Hardship Hearing (WC-185)

Request to DWC for a hardship hearing regarding workers compensation claim.

Request for Mediation (WC-184)

Request to DWC for a mediation regarding workers compensation claim.

Request for Services from the Missouri Workers' Safety Program (WSP-6)

A form requesting services from a workers' compensation program or the Missouri workers' safety program.

Self-Insurer’s Annual Financial Statement (WC-85)

An annual report of an individually self-insured employer’s audited financial statements.

Self-Insurer’s Payroll Report (WC-84)

An annual report of an individually self-insured employer’s Missouri payroll by class code and employee count by Missouri location.

Self-Insurer’s Report of Compensation Payments (WC-86)

An annual report of an individually self-insured employer’s Missouri compensation payments for the prior calendar year.

Self-Insurer’s Statement of Outstanding Losses (WC-83)

An annual report of an individually self-insured employer’s outstanding losses.

Stipulation for Compromise Settlement (WC-G-11)

A form submitted to an Administration Law Judge for approval of the settlement of a workers' compensation case.

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