Publications and Forms

Electronic File Transfer and Magnetic Media Reporting Specifications (MODES-INF-368)

This booklet contains instructions and specifications for electronic file transfer (Internet) or magnetic media reporting (compact disc) to the Missouri Division of Employment Security. A web page of this form is also available.

 
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.

 
Employer Benefit Charges (MODES-INF-280)

Information regarding the quarterly statement of benefit charges.

 
Employer Records Release Authorization (MODES-4385)
A form authorizing the release of employer records.
 
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.