Free Memorandum to Commercial Insurers (WC-240-3) - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

DIVISION OF WORKERS' COMPENSATION
3315 WEST TRUMAN BOULEVARD, ROOM 131 P.O. BOX 58 JEFFERSON CITY, MO 65102-0058 PHONE: 573-751-4231 FAX: 573-751-2012 www.dolir.mo.gov/wc E-mail: [email protected]

MEMORANDUM
TO: FROM: All Workers' Compensation Insurance Companies Cynthia Struemph Second Injury Fund Program Manager February 21, 2008

DATE:

SUBJECT: Affidavit of Zero Reporting For Calendar Year Second Injury Fund Surcharge Premiums

As required by Section 287.715 RSMo, you are required to submit a Second Injury Fund Surcharge report thirty days following the end of each quarter. However, beginning with calendar year 2008, and each year thereafter, you may complete the Affidavit of Zero Reporting For Calendar Year by the 1st Quarter Second Injury Fund Surcharge Form due date of April 30. The affidavit states that your company has had no direct written workers' compensation premiums to date for the calendar year in question. And if during the course of the calendar year your company begins to write workers' compensation premiums, your company will remit the appropriate Second Injury Fund Surcharge Forms and payments. You may find the forms on our website at http://www.dolir.mo.gov/wc/forms/FormsecInjFSur.htm. Please find the Affidavit for Zero Reporting For Calendar Year at the same location as the Second Injury Fund Surcharge Forms. You may complete the affidavit and submit it to us at the address on the affidavit. The completed affidavit will remain on file with the Division for the calendar year indicated. The Division will not be expecting the Quarterly Second Injury Fund Surcharge Forms for the year indicated on the affidavit unless you begin writing workers' compensation premiums during the calendar year. The affidavit is only valid for one year; it will need to be resubmitted each year if applicable. Please feel free to contact me at (573) 526-3505 or Carolyn Koetting at (573) 526-5756 with any questions or concerns regarding this affidavit.

WC-240-3 (02-08) AI