Form WC-84: Self-Insurer's Payroll Report for the month of December of the reporting year. The location schedule must include street address, city, state, and ZIP code of all Missouri locations. 8 CSR 50-3.010(3)(G)4 requires such changes to be reported to the Division. Any location not reported to the Division is not authorized as a self-insured location and could create issues relating to the filing of First Reports of Injury.
*Please note that the highlighted areas on the forms are areas that MUST be completed.
Instructions:
- Name but the name of the self-insured entity
- Month date must for December of the filing year
- Address field must include city, state and zip
- Number of employees per location must be included
- Total number of employees for all locations must be included
- Total wages received monthly by all classes of employees must be included
