Request for Services (WSP-6)

The Missouri's Workers' Safety Program (MWSP) was created to help employers improve workplace safety and reduce workers' compensation insurance costs. At your request, your insurance carrier or the MWSP will assist you in creating a comprehensive safety and health management plan for your business. Visit labor.mo.gov/MWSP for more information or a list of certified independent consultants who can provide safety services.

Missouri Department of Labor
& Industrial Relations
Division of Labor Standards
PO. Box 58
Jefferson City, MO
65102-0058
Phone: 573-526-5757

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a PDF version of this form.

Business Information

Business Name

Sector Type

Private Sector

Public Sector (Government)

Address

City

State

ZIP

Phone

Website

Briefly describe your company's operations and final products. If more than one operation, list in primary order.

Contact Information

First Name

Last Name

Title

Phone Number

Workers' Compensation Insurance Information

Insurance Type

Private Insurance

Self-Insured

Self-Insured Trust

N/A

Name of Insurance Carrier or Trust, or Write Self

Request

NOTE: You may request services from both your insurance provider and the MWSP.

I am interested in receiving service from my insurance provider

Under Missouri law, §287.123, RSMo, all insurance carriers in the state are required to offer comprehensive safety engineering and management services upon request from insured employers. Many of these services are provided at no additional charge, as they are worked into the cost of the premium. Self-Insured Trusts are required to provide safety programs to their members under 8 CSR 50-3.010.

I am interested in receiving service from the Missouri Workers’ Safety Program

The Missouri Workers’ Safety Program provides free safety and health consultation services to businesses in the state. It also offers service to Self-Insured Employers and Trusts that need assistance in meeting their obligations for a safety program under 8 CSR 50-3.010.

Name of Authorizing Representative

First Name

Last Name

Date

Missouri Department of Labor and Industrial Relations is an equal opportunity employer/program.

TDD/TTY: 800-735-2966 Relay Missouri: 711