WC-131 (01-18) AI MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS INDIVIDUAL SELF -INSURED EMPLOYER INFORMATION 3315 W. Truman Blvd. P.O. Box 58 Jefferson City, MO 65102- 0058 573-751- 4231 www.labor.mo.gov/DWC 1. EMPLOYER ( legal entity holding Missouri self- insurance au thority ) Name of Self - Insured Employer FEIN Number SIC/NAIC S Code Principal Contact for Self - Insurance (Officer or Manager in your organization responsible for maintaining your self-insurance authority) E mail P hone Number Mailing Address Fax Number City, State, ZIP Code Street Address City, State, ZIP Cod e 2. OTHER NAMES ( d / b /a222s) 226 Do you operate under any registered fictitious names in Missouri? Please list all. 1) 2) 3) 4) 3. PRIMARY CONTACT FOR SELF-INSURANCE (person responsible for day-to-day issues involving self-insurance and the reporting of injuries to your claim administrator ) Name and Title of Contact E mail P hone Number Address Fax Number City, State, ZIP Code FINANCIAL CONTACT (the Comptroller, Treasurer, or Chief Financial Officer) Name and Title of Contact E mail P hone Number Address Fax Number City, State, ZIP Code Missouri Division of Workers222 Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. American LegalNet, Inc. www.FormsWorkFlow.com WC-131-2 (01-18) AI 5. SELF - INSURANCE ANNUAL REPORT CONTACT (person responsible for responding to information contained in the Annual Reports submitted to the Division) Name and Title of Contact Email P hone Number Address Fax Number City, State, ZIP Code 6. SAFETY 226 In - House Contact Name and Title of Safety Manager/Administrator E mail P hone Number Address Fax Number City, State, ZIP Code Do you use an outside safety consultant certified by the Missouri Workers222 Safety Program? Yes No (If Yes, please fill in the following information.) Name and Title of Safety Consultant E mail P hone Number Address Fax Number City, State, ZIP Code 7. ULTIMATE PARENT COMPANY Name of Parent Company FEIN Number P hone Number Address City, State, ZIP Code Does the self -insured employer have any subsidiaries? Yes No Attach an organizational chart if there are any subsidiaries or other related companies. 8. CORPORATE LEGAL CO U NSEL (i n - house counsel for the se lf - insured employer ) Name and Title of Contact, Firm Name (if applicable) Email P hone Number Address Fax Number City, State, ZIP Code American LegalNet, Inc. www.FormsWorkFlow.com WC-131-3 (01-18) AI 9. CLAIMS ADMINISTRATION 226 Please list the location where claims are being handled for Missouri, NOT the office where the contract was signed. Has there been a change from the previous year? Yes No Please c heck if claims are or by SELF - ADMINISTERED ( IN - HOUSE ) THIRD - PARTY ADMINISTRATOR ( TPA ) EFFECTIVE DATE //. Name of Claims Administrator Company FEIN Number Contact Name and Title E mail P hone Number Address Fax Number City, State, ZIP Code Is the current TPA handling all previous and new claims? Yes No 10. INSURANCE CONSULTANT OR BROKER Change from previous year? Yes No Company Name Contact Name and Title E mail P hone Number Address Fax Number City, State, ZIP Code 11. ADMINISTRATIVE TAX AND SECOND INJURY FUND SURCHARGE CONTACT (person within your organization that handles Admin tax and SIF assessment) Change from previous year? Yes No Name and Title E mail P hone Number Address Fax Number City, State, ZIP Code 12. PLEASE INDICATE ANY SIGNIFICANT CHANGES IN YOUR OPERATIONS IN THE LAST YEAR (i.e., ownership, locations open/closed, product or operations) Attach additional sheet s , if necessary. American LegalNet, Inc. www.FormsWorkFlow.com