MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS SELFPAYMENTS This form must be completed and returned on or before March 31 to: MISSOURI DI P.O. BOX 58 JEFFERSON CITY, MO 65102-0058 SECTION I Official Name of Self-Insured Entity For Year Ending Federal Employer Identification No. Corporate Address Month and Date of Fiscal Year End During the Calendar Year Closed January 1 thru December 31, Compensation Paid Medical Paid Total Paid $ $ $ SECTION II Name, address, telephone number of service company which handled injury payments if used or of person processing such payments if self-administered. Service Company Name Address Address Address Telephone Number Telephone Number Telephone Number SECTION III Name, address, telephone number of person to be contacted in self-insured company (entity), responsible for annual reports and other matters pertaining to maintaining self-insured authority. Name Title Telephone Number Address City State ZIP Code Name of parent company, if a subsidiary: Is the self-insured entity or any parent company, currently under bankruptcy protection or considering filing for bankruptcy protection? Yes No . An authorized self-insurer, being duly sworn, state that the foregoing is a full and correct report of the information required in this statement. Signature Official Capacity Date Notary Public Embosser Seal State Subscribed and sworn before me, this Day of Notary Public Signature Notary Public Name (Typed or Printed) County (or) City of Year My Commission Expires USE RUBBER STAMP IN CLEAR AREA BELOW. WC-86 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com