Free 84-AI.qxd - Missouri


File Size: 212.2 kB
Pages: 1
Date: December 26, 2007
File Format: PDF
State: Missouri
Category: Workers Compensation
Author: es3375
Word Count: 111 Words, 1,322 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dolir.mo.gov/wc/forms/84-ai.pdf

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

Division of Workers' Compensation
JEFFERSON CITY, MISSOURI

Self-Insurer's Payroll Report
For the Month of _____________________ _______ Name _____________________________________________________________________________________________________ Address (Principal office) _____________________________________________________________________________________
No. Street City State Zip

Nature of Business __________________________________________________________________________________________
PART I
Give location of factories, offices, or other working places in MISSOURI and number of employees in each place.

PART II
CLASSIFICATIONS AND PAYROLL IN MISSOURI

Address

No. of Employees

Classification Code Description

Class Code 8810

Average Number of Employees 200

Wages Received Monthly by Each Class of Employee

(Example)

Clerical

$2,912,000

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ONLY LOCATIONS REPORTED TO THE DIVISION ARE APPROVED SELF-INSURED LOCATIONS.

_______________________________________
(Name of Person Making Report)

_______________________________________
(Title or Position)

WC-84 (10-03) AI