MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS Division of Workers' Compensation JEFFERSON CITY, MISSOURI Self-Insurer's Payroll Report For the Month of _____________________ _______ Name __________________________________________________________________________________________________________________ Address (Principal office) __________________________________________________________________________________________________ No. Street City State Zip Nature of Business ________________________________________________________________________________________________________ PART I Give location of factories, offices, or other working places in MISSOURI and number of employees in each place. PART II CLASSIFICATIONS AND ANNUAL PAYROLL IN MISSOURI Classification Code Description (Example) Clerical Class Code 8810 Average Wages Received Number of Monthly by Each Employees Class of Employee 200 $2,912,000 Address No. of Employees Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ONLY LOCATIONS REPORTED TO THE DIVISION ARE APPROVED SELF-INSURED LOCATIONS. ____________________________________________________________ (Name of Person Making Report) ____________________________________________________________ (Title or Position) WC-84 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com