Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Employees Religious Exception Affidavit and Waiver Form. This is a Missouri form and can be use in Workers Comp.
Loading PDF...
Tags: Employees Religious Exception Affidavit and Waiver, WC-138-3, Missouri Workers Comp,
Form 2 of 3
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
EMPLOYEE’S AFFIDAVIT AND WAIVER OF WORKERS’ COMPENSATION BENEFITS
TO BE FILED WITH THE §287.804 – Application for Religious Exception
Name of Employee (Last, First, MI)
SSN
Date of Birth (MM/DD/YYYY)
Mailing Address – Street
Phone Number (If Any)
City
County
State
Before me, the undersigned authority, personally appeared
sworn on this oath states as follows:
Zip Code (9-Digit)
who, being duly
(Name of Employee)
My name is
. I am of sound mind, capable of making this affidavit and wavier,
and personally acquainted with the facts herein stated. If the employee is a minor, the parent or guardian by signing
the application, states that he/she has explained the waiver of workers’ compensation benefits to the minor.
I do hereby state that I am a member of
. Its established
(Name of recognized religious sect or division)
tenets and/or teachings conscientiously oppose member acceptance of any private or public insurance benefits which
makes payments in the event of death, disability, old age, retirement or towards the cost of medical bills and provision
of services for medical bills (including the benefits of any insurance system established by the Federal Social Security
Act, 42 U.S.C. 301 to 42 U.S.C. 1397jj), and I adhere to said tenets and/or teachings.
I am, therefore, knowingly and voluntarily waiving my rights to any benefits under the Missouri Workers’ Compensation
Law, Chapter 287, RSMo. I understand and agree that no medical treatment, compensation and death benefits or
payments of any kind under Chapter 287, RSMo, will be provided to me in the event of a work-related accident,
injury or occupational disease.
I understand that an exception granted to me shall be valid until I rescind my election to reject benefits under the
workers’ compensation law or the religious sect or division that I am a member of ceases to meet the requirements of
§287.804(1) RSMo.
I understand that providing false and fraudulent information on this affidavit and waiver would be subject to
investigation by the Division’s Fraud & Noncompliance Unit and possible prosecution pursuant to §287.128 RSMo
or other applicable laws.
STATE OF MISSOURI
COUNTY OF
)
)
)
Signature of Employee and Date
(Or Parent or Guardian in Case of Minor)
Subscribed and sworn/affirmed to before me this
day of
, 20
.
Relationship to Minor
My Commission Expires:
Notary Public
(Notarial Seal)
WC-138-3 (02-06) AI
American LegalNet, Inc.
www.FormsWorkflow.com
