MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS NONCOMPLIANCE REFERRAL FORM (Complete the form to report a business for not carrying workers' compensation insurance.) P.O. Box 1009 Jefferson City, MO 65102-1009 573-526-6630 www.labor.mo.gov/DWC/report_fraud.asp General guidelines: Employers with five or more employees are required to carry workers' compensation insurance, with the exception of the construction industry which requires employers with one or more employees to carry workers' compensation insurance. If you would like more information, please call 800-592-6003 or visit www.labor.mo.gov/DWC/Employers/report_respon.asp to read more about employers' responsibilities and liability for coverage. Instructions: Please complete the required fields in order for the Fraud and Noncompliance Unit ("Unit") to conduct an investigation. Employer Information: Name of Business (Required) Owner's Name (if known) Address City (Required) State County ZIP Business Phone Number If address is not known, what is the location of the jobsite or directions to the jobsite? Type of business (if known) Construction Government Retail Trucking/Transportation Estimated # of Employees Type of work performed Description of the Alleged Violation: Health Care Other Manufacturing Work-Related Injury/Death Information: Has this employer had a work-related injury or death? Yes No If "Yes," please provide the following information about the injured/deceased employee, if known: First Name Last Name Address City Date of Injury Phone Number State ZIP WC-258 (03-12) AI American LegalNet, Inc. www.FormsWorkFlow.com Contact Information: Please provide your contact information. As our investigation progresses, we may need to contact the person filing the complaint to obtain more details. Also, if you choose to remain anonymous, it will not be possible for us to notify you of the outcome of the investigation. First Name Last Name Address City Phone Number E-mail Address State ZIP Please note that all records, reports, tapes, photographs, and similar materials or documents submitted to the Fraud and Noncompliance Unit or obtained by the Unit that is used to conduct an investigation for any violation under the workers' compensation law is confidential pursuant to §287.128.9 RSMo and is not subject to chapter 610, RSMo. After the Unit completes its investigation it presents its findings to the Division Director who may refer the matter to the Missouri Attorney General's Office for prosecution. WC-258-2 (03-12) AI American LegalNet, Inc. www.FormsWorkFlow.com