MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS MISSOURI WORKERS' SAFETY PROGRAM REQUEST FOR SERVICES P.O. Box 58 Jefferson City, MO 65102-0058 573-526-5757 www.labor.mo.gov/DWC The Missouri 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 www.labor.mo.gov/MWSP for more information or a list of certified independent consultants who can provide safety services. I. BUSINESS INFORMATION BUSINESS NAME STREET ADDRESS CITY PHONE WEBSITE BRIEFLY DESCRIBE YOUR COMPANY'S OPERATIONS AND FINAL PRODUCTS. IF MORE THAN ONE OPERATION, LIST IN PRIMARY ORDER. STATE FAX ZIP PLEASE CHECK ONE: Private Sector Public Sector (Government) II. CONTACT INFORMATION NAME OF CONTACT PERSON E-MAIL ADDRESS TITLE PHONE III. WORKERS' COMPENSATION INSURANCE INFORMATION PLEASE CHECK ONE NAME OF INSURANCE CARRIER OR TRUST, OR WRITE SELF Private Insurance Self-Insured Self-Insured Trust IV. 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 requests 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. V. AUTHORIZED SIGNATURE AUTHORIZED SIGNATURE DATE Missouri Division of Workers' Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. WSP-6 (02-14) AI American LegalNet, Inc. www.FormsWorkFlow.com