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DIVISION OF WORKERS’ COMPENSATION
INDIVIDUAL SELFINSURED EMPLOYER INFORMATION
Please Note: Form must be completed entirely even if there are no changes from previous year.
1. EMPLOYER (legal entity holding Missouri selfinsurance authority)
NAME OF SELFINSURED EMPLOYER
FEIN NUMBER SIC/NAIC CODE
MAILING ADDRESS
CITY, STATE, ZIP CODE
STREET ADDRESS
CITY, STATE, ZIP CODE
2. OTHER NAMES (d/b/a’s) – Do you operate under any fictitious company names in Missouri? Please list all.
1. 2.
3. 4.
5. 6.
3. PRINCIPAL CONTACT FOR SELFINSURANCE (the person in your organization responsible for maintaining your
selfinsurance authority)
CONTACT NAME JOB TITLE
EMAIL TELEPHONE NO.
ADDRESS FAX NO.
CITY, STATE, ZIP CODE
4. ANNUAL REPORT CONTACT
CONTACT NAME JOB TITLE
EMAIL TELEPHONE NO.
ADDRESS FAX NO.
CITY, STATE, ZIP CODE
5. SAFETY – In House Contact
NAME OF SAFETY MANAGER/ADMINISTRATOR JOB TITLE
EMAIL TELEPHONE NO.
ADDRESS FAX NO.
CITY, STATE, ZIP CODE
Do you use an outside safety consultant? Yes No (If “Yes,” please fill in the following information.)
SAFETY CONSULTANT NAME JOB TITLE
EMAIL TELEPHONE NO.
WC131 (0107) AI
ADDRESS FAX NO.
CITY, STATE, ZIP CODE
6. PARENT COMPANY – If applicable.
NAME OF PARENT COMPANY
FEIN NUMBER TELEPHONE NO.
ADDRESS
CITY, STATE, ZIP CODE
7. CLAIMS ADMINISTRATION – Please list the location where claims are being handled for Missouri, NOT the office
where the contract was signed.
(INHOUSE) (TPA) EFFECTIVE DATE: / /
SELFADMINISTERED THIRD PARTY ADMINISTRATOR
NAME OF CLAIMS ADMINISTRATOR
FEIN NUMBER TELEPHONE NO.
CONTACT NAME FAX NO.
EMAIL
ADDRESS
CITY, STATE, ZIP CODE
Is the current TPA handling all previous & new claims? Yes No
8. INSURANCE CONSULTANT OR BROKER
COMPANY NAME
CONTACT NAME
EMAIL TELEPHONE NO.
ADDRESS FAX NO.
CITY, STATE, ZIP CODE
9. ADMINISTRATIVE TAX AND SECOND INJURY FUND SURCHARGE CONTACT
NAME & TITLE
EMAIL TELEPHONE NO.
ADDRESS FAX NO.
CITY, STATE, ZIP CODE
10. PLEASE INDICATE ANY SIGNIFICANT CHANGES IN YOUR OPERATIONS IN THE LAST YEAR
(i.e., ownership, locations open/closed, product or operations)
WC1312 (0107) AI
WC1312 (0107) AI