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Publications and Forms

Escrow Agreement (WC-82E)

An Escrow Agreement; one of three options available to meet the self-insurance security requirement.

Group Insurance Checklist (WC-239)

The checklist of required items and information that must accompany the Application for Self-Insurance Trust (WC-81A).

Guaranty to Satisfy Compensation Claims Under Workers’ Compensation Law of Missouri (WC-82A)

A guaranty of a third party to satisfy an individually self-insured employer’s workers’ compensation obligations under Missouri law.

Joint Motion for Change of Venue (WC-281)

This form allows attorneys that are parties to a case to jointly submit a motion for change of venue.  All parties must agree to the change of venue. 

Memorandum to Commercial Insurers (WC-240-3)

A memo regarding the affidavit of zero reporting for commercial insurers.

Physicians Report on Eye Injuries (WC-241)

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

Religious Exception Application and Affidavit Instructions (WC-138-7)

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

Religious Exception Information (WC-138-A)

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

Report Your Workplace Injury/Occupational Disease or Repetitive Trauma Injury (WC-280)

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

Self-Insurance By-Laws - Sample (WC-238)

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