WC-84 Instructions

Form WC-84: Self-Insurer's Payroll Report for the month of December of the reporting year. The location schedule must include street address, city, state, and ZIP code of all Missouri locations. 8 CSR 50-3.010(3)(G)4 requires such changes to be reported to the Division. Any location not reported to the Division is not authorized as a self-insured location and could create issues relating to the filing of First Reports of Injury.

*Please note that the highlighted areas on the forms are areas that MUST be completed.


  • Name but the name of the self-insured entity
  • Month date must for December of the filing year
  • Address field must include city, state and zip
  • Number of employees per location must be included
  • Total number of employees for all locations must be included
  • Total wages received monthly by all classes of employees must be included
WC-84 Instructions

DISCLAIMER - More Information

The Employers, Insurers, TPAs section of the Workers' Compensation portion of this web site is targeted specifically to employers, insurers and third party administrators and is intended to be a resource throughout the workers' compensation claim process. It is NOT intended to be a substitute for legal representation.

Injured workers seeking information about the workers' compensation process should use the Injured Workers section of the Workers' Compensation web site to find information targeted specifically to them.

Additional information about Missouri Workers' Compensation laws, the Division of Workers Compensation, the Second Injury Fund and more may be found via the Workers' Compensation home page.