A form to be completed by physician examining a workers compensation eye injury.

 

The Division uses the Quarterly Wage Report Continuation Sheet to allow reporting of additional employees when there are more employees than will fit on the Quarterly Contribution and Wage Report (MODES-4). This form MODES-10B should be attached to the MODES-4.

 

Instructions for completing the application, affidavit and waiver of workers compensation benefits.

 

Information regarding employees who wish to be exempt from workers' compensation law because of religious reasons.

 

This form allows employees to provide proper written notification to their employer when a workplace injury/occupational disease occurs.

 

The form to be completed by an employee who is requesting a rescission from a previously received religious exemption.

 

A self-evaluation questionnaire to be completed by an unemployed claimant.

 

A sample of by-laws that may be used as a reference when forming a new group trust.

 

Certification procedures for a self-insured group trust’s safety program.

 

Employers use the Social Security Number Correction form to correct the social security number of an employee whose number was erroneously reported. Employers may correct the social security number of one employee on each correction form, but the form may be applicable to more than one calendar quarter. After making the correction, please return to:

 


Division of Employment Security

Attn: Employer Accounts Unit

P. O. Box 59

Jefferson City, MO 65104-0059

or it can be faxed to 573-751-9705.