Publications and Forms

EDI File Matrix, IAIBC release first report of injury.

EDI Missouri Data Dictionary (WC-EDI-219)

A dictionary of Missouri IAIABC data definitions.

Electronic Data Distribution Trading Partner Profile (Receiver's Specifications) (WC-133)

A form regarding the profile of an electronic data distribution trading partner (Receiver's specifications).

Electronic Partnering/Confidentiality Agreement (Second Injury Fund Surcharge) (WC-276)

A form to be completed by the employer/insurer regarding the electronic filing of the quarterly Second Injury Fund Surcharge Report Forms.

Entry of Appearance (WC-200)

A form for an attorney to enter his or her appearance in a workers' compensation medical fee dispute.

Entry of Appearance (WC-235)

A form for an attorney to make an entry of appearance in a workers' compensation case.

Fraud and Noncompliance Referral Form (WC-258)

Complete the form to report a business for not carrying workers' compensation insurance.

Group Trust New Member Application Checklist (WC-269)

The checklist of required items and information that must accompany the Application for Membership (WC-81B).

Health Care Provider's Response to Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-202)

A health care provider’s response to a request for an award on undisputed facts in regard to an application for direct payment medical fee dispute.

Individual Self Insured Employer Information Sheet (WC-131)

Current contact information to be submitted by self-insured employers on an annual basis and as needed.

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Frequently Requested Forms

Claim for Compensation (Workers' Comp.)
Quarterly Contribution and Wage Report (Employment Security)
Contribution & Wage Adjustment Report (Employment Security)
Disability Schedule and Benefit Limits (Workers' Comp.)
Certificate to Employ a Child 14 or 15 Years of Age During School Term
Certificate to Employ a Child 14 or 15 Years of Age During Non-School Term
Missouri Minimum Wage Poster
Request for Mediation (Workers' Comp.)
Request for Pre-Hearing (Workers' Comp.)
Information for Workers (Employment Security)
Employers' Rights and Responsibilities (Employment Security)

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