Free Self-Insurer's Report of Compensation Payments (WC-86) - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION

FOR YEAR ENDING

SELF-INSURER'S REPORT OF COMPENSATION PAYMENTS
THIS FORM MUST BE COMPLETED AND RETURNED ON OR BEFORE MARCH 31 TO: MISSOURI DIVISION OF WORKERS' COMPENSATION P.O. BOX 58 JEFFERSON CITY, MO 65102-0058 SECTION I
OFFICIAL NAME OF SELF-INSURED ENTITY FEDERAL EMPLOYER IDENTIFICATION NO.

CORPORATE ADDRESS

MONTH AND DATE OF FISCAL YEAR END

DURING THE CALENDAR YEAR CLOSED JANUARY 1, THRU DECEMBER 31,
COMPENSATION PAID MEDICAL PAID TOTAL PAID

$
SECTION II

$

$

NAME, ADDRESS, TELEPHONE NUMBER OF SERVICE COMPANY WHICH HANDLED INJURY PAYMENTS IF USED OR OF PERSON PROCESSING SUCH PAYMENTS IF SELF-ADMINISTERED. SERVICE COMPANY NAME

ADDRESS

ADDRESS

ADDRESS

TELPHONE NUMBER

TELEPHONE NUMBER

TELEPHONE NUMBER

SECTION III
NAME, ADDRESS, TELEPHONE NUMBER OF PERSON TO BE CONTACTED IN SELF-INSURED COMPANY (ENTITY), RESPONSIBLE FOR ANNUAL REPORTS AND OTHER MATTERS PERTAINING TO MAINTAINING SELF-INSURED AUTHORITY. NAME TITLE TELEPHONE NUMBER

ADDRESS

CITY

STATE

ZIP CODE

NAME OF PARENT CO. IF A SUBSIDIARY:
IS THE SELF-INSURED ENTITY OR ANY PARENT COMPANY, CURRENTLY UNDER BANKRUPTCY PROTECTION OR CONSIDERING FILING FOR YES NO IF "YES," ATTACH A STATEMENT WITH DETAILS REGARDING THE BANKRUPTCY ACTION. BANKRUPTCY PROTECTION?

AN AUTHORIZED SELF-INSURER, BEING DULY SWORN, STATE THAT THE FOREGOING IS A FULL AND CORRECT REPORT OF THE INFORMATION REQUIRED IN THIS STATEMENT. SIGNATURE OFFICIAL CAPACITY DATE

NOTARY PUBLIC EMBOSSER SEAL

STATE

COUNTY (OR) CITY OF

SUBSCRIBED AND SWORN BEFORE ME, THIS DAY OF YEAR USE RUBBER STAMP IN CLEAR AREA BELOW. MY COMMISSION EXPIRES NOTARY PUBLIC SIGNATURE

NOTARY PUBLIC NAME (TYPED OR PRINTED)

WC-86 (03-07) AI