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Publications and Forms

Physicians Report on Eye Injuries (WC-241)

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

Quarterly Wage Report Continuation Sheet (MODES-10B)

The Division uses the Quarterly Wage Report Continuation Sheet to allow reporting of additional employees when there are more employees than will fit on the Quarterly Contribution and Wage Report (MODES-4). This form MODES-10B should be attached to the MODES-4.

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-Evaluation Questionnaire / Work Search Record (MODES-4633)

A self-evaluation questionnaire to be completed by an unemployed claimant.

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.

Self-Insured Trust Safety Program Initial Certification Procedures (WC-129-AI)

Certification procedures for a self-insured group trust’s safety program.

Social Security Number Correction (MODES-4427)

Employers use the Social Security Number Correction form to correct the social security number of an employee whose number was erroneously reported. Employers may correct the social security number of one employee on each correction form, but the form may be applicable to more than one calendar quarter. After making the correction, please return to:
 

Division of Employment Security
Attn: Employer Accounts Unit
P. O. Box 59
Jefferson City, MO 65104-0059
or it can be faxed to 573-751-9705.

Trade Adjustment Assistance For Workers (MODES-INF-195)

Information about Trade Adjustment Assistance for workers who have lost their job due to foreign trade.

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