Free Affidavit of Zero Reporting - - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058

AFFIDAVIT OF ZERO REPORTING ­ COMMERCIAL INSURERS ONLY FOR CALENDAR YEAR
Company Name, Address and NAIC #:

Company Contact, Phone Number and E-mail Address:

Name of President/Executive Officer

Name of Person Completing Affidavit/Title

Before me, the undersigned authority, personally appeared being duly sworn on oath stated that: I am the President/Executive Officer or the Person Completing the Affidavit (if different from the President/Executive Officer) respectively of the

who,

and I am of sound mind, capable of making this affidavit and
(Name of Employer)

acquainted with the facts herein stated. The company is reporting zero Second Injury Fund Surcharge due pursuant to Section 287.715, RSMo et seq. for the calendar year . This is based upon the fact that the company had no

Missouri direct written workers' compensation premiums to date for the calendar year in question. If during the course of the calendar year the direct written workers' compensation premiums become something other than zero, the company will begin remitting the appropriate Second Injury Fund Surcharge forms and payments. Signature of President/Executive Officer Signature of Person Completing Affidavit

Notary Public Embosser or State of Black Ink Rubber Stamp Seal Subscribed and Sworn Before Me, This Day Of Notary Public Signature Notary Public Name (Typed or Printed) Year My Commission Expires

County (Or City of St. Louis) Use Rubber Stamp in Clear Area Below

WC-240 (02-08) AI