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