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Publications and Forms

Affidavit of Exemption for Workers' Compensation Insurance (WC-134)

An affidavit that construction industry business owners who are not required to purchase workers’ compensation insurance may use to aid them in obtaining business licenses from some cities and counties.  Note: This form should not be sent to the Division of Workers’ Compensation.

Application for Authority to Self-Insure (WC-81)

The application to be completed by an employer applying to individually self-insure.

Application for Consultation Service Form (LS-25)

An application for a Missouri On-Site Safety and Health Consultation.

Application for Group Self-Insurance (WC-81A)

The application to be completed by a group of employers applying to form a self-insured group trust.

Auditing Procedures for Applicants for Individual Self-Insurance (WC-130-AI)

The safety auditing procedures for those employers applying to individually self-insure.

Authorization for Release of Confidential Information (WC-249-3)

An authorization for release of confidential information that must accompany the Irrevocable Letter of Credit (WC-249).

Bond of Employer Carrying His Own Risk (WC-82B)

A Surety Bond; one of three options available to meet the self-insurance security requirement.

Checklist for Individual Self-Insurance Applications (WC-128)

The checklist of required items and information that must accompany the Application for Authority to Self-Insure (WC-81).

Child Labor Complaint Form (LS-53)

A form to submit a complaint about child labor.

Classifying Employees for Unemployment Insurance Tax Purposes (MODES-INF-310)

Information for employers regarding classifying employees for unemployment insurance tax purposes.

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