Forms

PURPOSE: This rule sets forth the forms required for filing with the division by the employee, employer and insurer. Included are instructions to obtain forms. Forms required for filing with the division are listed in this rule, together with a few other forms required of employees, employers and insurers. Under the provisions of section 287.630, RSMo, these forms are provided free of charge. Those requiring such forms should send their requests to the division at Jefferson City, giving the form serial number and the quantity needed. Some forms, such as subpoenas and Forms 42 and 43, which have to be executed separately for individual cases, cannot, of course, be sent out in quantities. The only cost in connection with procuring the forms is transportation charges. Form No. Use 1 Report of Injury 2 Receipt and Notice of Termi- nation of Compensation 2-A Receipt for Compensation 3 Notice of Commencement of Compensation 6 Notice of Termination of Compensation 8 Request for Lump Sum Settlement 9 Surgeon’s Report 9-A Physician’s Report on Eye Injuries 21 Claim for Compensation 22 Answer to Claim for Com- pensation 25 Subpoena 25-A Subpoena Duces Tecum 42 Special Order for Additional Medical 43 Authorization to Inspect and/or Copy Medical Records 65-B Withdrawal of Employer’s Acceptance of Law 75 Memorandum of Insurance Coverage 8 Application for Authority to Self-Insure 82 (Bond) Bond of Self-Insurer 82 (Escrow) Escrow Agreement of Self- Insurer 83 Self-Insurer’s Statement of Outstanding Disability Claims 84 Self-Insurer’s Payroll Report 85 Self-Insurer’s Annual Finan- cial Statement 86 Self-Insurer’s Report of Com- pensation Payments AUTHORITY: section 287.650, RSMo 1986.* Original rule filed Aug. 26, 1975, effective Sept. 5, 1975. *Original authority: 287.650, RSMo 1939, amended 1949, 1961, 1980, 1993, 1995, 1998.