Form WC-84 Instructions

Form WC-84: Self-Insurer's Payroll Report for the month of December of the reporting year. The location schedule must include street address, city, state, and ZIP code of all Missouri locations. 8 CSR 50-3.010(3)(G)4 requires such changes to be reported to the Division. Any location not reported to the Division is not authorized as a self-insured location and could create issues relating to the filing of First Reports of Injury.

*Please note that the highlighted areas on the forms are areas that MUST be completed.

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