Mo. Code Regs. tit. 8 § 50-5.070
PURPOSE: This rule sets forth the forms required for filing with the division by the employee, employer and insurer. Included are instructions to obtain forms.
Forms required for filing with the division are listed in this rule, together with a few other forms required of employees, employers and insurers. Under the provisions of section 287.630, RSMo, these forms are provided free of charge. Those requiring such forms should send their requests to the division at Jefferson City, giving the form serial number and the quantity needed. Some forms, such as subpoenas and Forms 42 and 43, which have to be executed separately for individual cases, cannot, of course, be sent out in quantities. The only cost in connection with procuring the forms is transportation charges.
| Form | |
| No. | Use |
| 1 | Report of Injury |
| 2 | Receipt and Notice of Termnationi |
| of Compensation | |
| 2-A | Receipt for Compensation |
| 3 | Notice of Commencement of |
| Compensation | |
| 6 | Notice of Termination of |
| Compensation | |
| 8 | Request for Lump Sum |
| Settlement | |
| 9 | Surgeon's Report |
| 9-A | Physician's Report on Eye |
| Injuries | |
| 21 | Claim for Compensation |
| 22 | Answer to Claim for Compensation |
| 25 | Subpoena |
| 25-A | Subpoena Duces Tecum |
| 42 | Special Order for Additional |
| Medical | |
| 43 | Authorization to Inspect |
| and/or Copy Medical | |
| Records | |
| 65-B | Withdrawal of Employer's |
| Acceptance of Law | |
| 75 | Memorandum of Insurance |
| Coverage | |
| 8 | Application for Authority to |
| Self-Insure | |
| 82 (Bond) | Bond of Self-Insurer |
| 82 (Escrow) | Escrow Agreement of Self-Insurer |
| 83 | Self-Insurer's Statement of |
| Outstanding Disability Claims | |
| 84 | Self-Insurer's Payroll Report |
| 85 | Self-Insurer's Annual Financial |
| Statement | |
| 86 | Self-Insurer's Report of Compensation |
| Payments |
8 CSR 50-5.070
*Original authority: 287.650, RSMo 1939, amended 1949, 1961, 1980, 1993, 1995, 1998.