Individual Self Insured Employer Information Sheet: is to be fully completed including e-mail addresses and any fictitious (d/b/a) names registered with the Missouri Secretary of State. Please note that the primary contact shown should be the person responsible for maintaining the employer’s Missouri self-insurance authority.
*Please note that the highlighted areas on the forms are areas that MUST be completed (all fields on the 3 page form).
The Employers, Insurers, TPAs section of the Workers' Compensation portion of this web site is targeted specifically to employers, insurers and third party administrators and is intended to be a resource throughout the workers' compensation claim process. It is NOT intended to be a substitute for legal representation.
Injured workers seeking information about the workers' compensation process should use the Injured Workers section of the Workers' Compensation web site to find information targeted specifically to them.
Additional information about Missouri Workers' Compensation laws, the Division of Workers Compensation, the Second Injury Fund and more may be found via the Workers' Compensation home page.