Free Religious Exception Application and Affidavit Instructions (WC-138-7) - Missouri

INSTRUCTIONS FOR COMPLETING THE SECTION 287.804 RSMo EMPLOYEE'S APPLICATION, AFFIDAVIT AND WAIVER OF WORKERS' COMPENSATION BENEFITS
1) The Section 287.804 ­ Employee's Application For Religious Exception From the Provisions of the Missouri Workers' Compensation Law, the Employer's Affidavit of Exception From Workers' Compensation Benefits and the Employee's Affidavit and Waiver of Workers' Compensation Benefits must be mailed at the same time to the Missouri Division of Workers' Compensation (hereafter "Division") at the address below. You must submit the original of Forms WC-138, WC-138-3 and WC-138-5. 2) If an employee works for two or more employers that are members of a recognized religious sect or division, a separate application must be submitted for each employer. 3) If an employee goes to work for another employer that is a member of a recognized religious sect or division, the employee needs to file another application for religious exception based upon employment with the new employer. 4) The employee must notify the Division in writing of any rescission to the rejection of workers' compensation coverage granted by the Division within thirty (30) days, after one of the following occurs: · · · The employee is no longer a member of a recognized religious sect or division; The employer is no longer a member of a recognized religious sect or division; or The employee is no longer employed by the employer.

5) Both the employer and employee MUST fill out all information requested on the form. Both MUST complete the form in black ink or use a minimum of 10-point font. 6) The employee and employer must sign the form and the signature must be in black ink and properly notarized. If the employee is a minor, the parent or guardian must sign and submit the application. Please note the relationship on the signature line. The minor's name and birth date must be used on the employee portion of the application. 7) The notary stamp on the document must be a black ink rubber stamp with the words "notary seal," "notary public," and "State of Missouri." A notarized signature by a Notary Public commissioned in another state is acceptable as long as he or she meets that state's requirements. 8) Employee's Social Security Number (SSN) or, if none, the date of birth and employer's Federal Employee Identification Number (FEIN) or, if none, the SSN must be included. 9) Signature date of employee and notary and signature date of employer and notary must match. 10) Forms that are illegible in any part and cannot be reproduced in the Division's image system will be returned. The Division does not accept fax filings. The forms must be mailed to: Division of Workers' Compensation Attn: Religious Exception P.O. Box 58 Jefferson City, MO 65102-0058 If you have any questions, please call 1 (800) 775-2667.

WC-138-7 (02-06) AI