MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS SECTION 287.804 ­ EMPLOYEE'S APPLICATION FOR RELIGIOUS EXCEPTION FROM THE PROVISIONS OF THE MISSOURI WORKERS' COMPENSATION LAW Must be filed along with the Employee's Affidavit and Waiver of Workers' Compensation Benefits and the Employer's Affidavit of Exception from Workers' Compensation Benefits. Name of Employee (Last, First, MI) Mailing Address ­ Street City 1. Name of Employer 2. Address of Employer 3. Employer is County State SSN Form 1 of 3 Date of Birth (MM/DD/YYYY) Phone Number ZIP Code (9-Digit) Sole Proprietor Partnership 4. (a) Total number of all persons employed by the employer as of the date of application (b) Total number of employees for whom exception is sought 5. What is the employer's current workers' compensation insurance coverage status? Insured Uninsured 6. If insured, insurance company name 7. (a) Full name of religious sect including division thereof (b) Name and address of local leader of the religious sect named in (a) (c) Does this religious sect provide financial and medical assistance for injured members and their dependents? Yes No 8. Section 287.804.4 RSMo states as follows: Any rejection pursuant to subsection 1 of this section shall be prospective in nature and shall entitle the employee only to reject such benefits that accrue on or after the date the rescission form is received by the insurance company. 9. Signature of Employee (or Parent or Guardian in case of minor) (Relationship to minor) 10. Division Use Only: Date Stamp: Date Application has all forms included: Application granted: Application returned: .......... .......... .......... .......... .......... .......... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. . . . . .. . . . . .. . . . . .. . . . . .. . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. WC-138 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com