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Publications and Forms

Notice of Opening or Closure of Mines (LS-66)

A form to notify the Mine and Cave Safety Program when a Missouri mine or cave is opening or closing. Report Online

Project Notification - Contractor Information (PW-2)

A project notification containing contractor information.

Proposed Rates for Group Trust Self-Insurance (WC-127)

A form to submit proposed rates for a self-insured group trust.

Questions and Affidavit Regarding Benefit Sources and Payments - Affidavit Form A (WCT-2)

Questions and affidavit for claimant regarding benefit sources and payments, form A.

Questions and Affidavit Regarding Completeness of Medical Information Submitted - Affidavit Form E (WCT-6)

Questions and affidavit for claimant regarding completeness of medical information submitted, form E.

Questions and Affidavit Regarding Due Diligence in Enforcing the Judgment - Affidavit Form D (WCT-5)

Questions and affidavit for claimant regarding due diligence in enforcing the judgment, form D.

Questions and Affidavit Regarding Lost Income - Affidavit Form B (WCT-3)

Questions and affidavit for claimant regarding lost income, form B.

Questions and Affidavit Regarding Waiver of Final Judgment and Requirement - Affidavit Form C (WCT-4)

Questions and affidavit for claimant regarding waiver of final judgment and requirement, form C.

Report Unemployment Insurance (UI) Fraud (MODES-4631)

A form used to report unemployment insurance fraud.

Request by a Health Care Provider for Case Status Information to file a Medical Fee Dispute Application (WC-194)

A form for use by health care provider to determine case status information to file a medical fee dispute application.

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