Department of Labor and Industrial Relations

Department Brochures
Division of Employment Security
Division of Labor Standards
Division of Workers' Compensation
Labor and Industrial Relations Commission
Missouri Commission on Human Rights
State Board of Mediation
Federally Required Posters

Division of Employment Security

Appeals

• Application For Review (MOIC-L-6)
• Information for Appeals Tribunal Hearings (MODES-INF-166)
• 8-B Unemployment Insurance Notice of Appeal (Fillable and Printable)
  • Instructions for completing the Form 8-B.

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Unemployed Workers

• Work Search Record (MODES-4541)
• Change My Payment Method for Unemployment Insurance On-line Claims
• Direct Deposit Authorization/Change Request (Form for Mailing) (MODES-B-6-5)
• Claimant Records Release Authorization (MODES-4384)
• Application For Review (MOIC-L-6)
• What You Need To Know About Unemployment Insurance in Missouri (MODES--INF-170)
• Lo que necesita saber sobre el Seguro por Desempleo de Missouri (MODES-INF-170-S)
• Filing for Unemployment Insurance Benefits in Missouri (MODES-INF-288-5)
• Para tramitar beneficios de Seguro por Desempleo en Missouri (MODES-INF-288-5-S)
• Shared Work Program: Information for Employees (MODES-INF-300)
• Obtaining Unemployment Records: Procedures and Practices(MODES-INF-326)
• Unemployment Benefits General Information (MODES-4603)
• Missouri Access MasterCard®/Debit Card Information(MODES-4606)
• Report Worker Misclassification/1099 Abuse (MODES-4610)
• Report Unemployment Insurance (UI) Fraud (MODES-4631)
• Information for Appeals Tribunal Hearings (MODES-INF-166)
• Missouri Extended Benefits Program (MODES-4616)
• Missouri Career Center Flier

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Employers

Posters

• Notice To Workers Concerning Unemployment Benefits (MODES-B-2)
• Spanish Version - Notice To Workers Concerning Unemployment Benefits (MODES-B-2-S)
• Importance of Filing Reports/File Quarterly Reports When Due (MODES-INF-394)

Brochures

• Unemployment Insurance Facts (MODES-INF-149)
• Employers' Rights and Responsibilities (MODES-INF-151)
• Employer Benefit Charges (MODES-INF-280)
• Shared Work Program for Employers (MODES-INF-301)
• Shared Work Program for Employees (MODES-INF-300)
• Who Are Employees? (MODES-INF-310)
• Obtaining Information from Division of Employment Security Records (MODES-INF-326)
• Unemployment Insurance Claims (MODES-INF-353)
• Payroll Records Required By Law (MODES-31)
• Unemployment State Tax Automated Reporting - USTAR pamphlet (MODES-INF-395)
• Information for Appeals Tribunal Hearings - Unemployment Benefits (MODES-INF-166)
• Unemployment Tax Tips for Employers (MODES-4619)

Forms

• Taxpayer Power of Attorney Form (MODES-4444) (Microsoft Word format)
• Employer Records Release Authorization (MODES-4385)
• Application For Review (MOIC-L-6)
• Register for an account number
  • Online Business Registration for New Employers <-- Register for Business Taxes Here
  • Report to Determine Liability Status (MODES-2699-5)
    The Division uses the Report to Determine Liability Status to determine whether an entity is liable for unemployment tax as a new or successor employer. The form must be completed even if the entity is not liable so that the Division can follow up at a time when liability may have been achieved or eliminate the entity from further follow-ups.
    • Download the Form (Microsoft Word format)
    • Download the Instruction
• Importance of Filing Reports/File Quarterly Reports When Due (MODES-INF-394)
• Report that a business has stopped employing workers, or the closure, sale or partial sale of a business
  • Internet USTAR <--Report Change in Business/Employment Here
  • Report on Change of Business Operations (MODES-9)
    An employer uses the Report on Change of Business Operations to inform the Division when it has sold all or part of its business, closed its business, stopped employing workers, or changed its name or address. The Division evaluates the information from the form to determine whether the employer's account should be updated, closed, transferred, or left unchanged.
• Interstate Reciprocal Coverage Arrangement
  • Employer's Election to Cover Multi-State Workers Under the Missouri Employment Security Law (MODES-2019) (Microsoft Word format)
• Report wages and tax for a quarter
  • Internet USTAR <--File Quarterly Report Here
  • Quarterly Contribution and Wage Report (MODES-4-7)
    Employers use the Quarterly Contribution and Wage Report to report wages of their employees to the Division of Employment Security. Each liable employer is required to file this report each quarter even if it has paid no wages that quarter or if its assigned tax rate is zero.
    • Download: Quarterly Contribution and Wage Report Spreadsheet* This is an Excel fillable form. For a blank printable form, use the following bullet point.
    • Download the Form - this form is a "print only" form.
    • Download the Instruction
• Report wages when there are too many workers to fit on the Quarterly Contribution and Wage Report
  • Quarterly Wage Report Continuation Sheet (MODES-10B)
    The Division uses the Quarterly Wage Report Continuation Sheet to allow reporting of additional employees when there are more employees than will fit on the Quarterly Contribution and Wage Report (MODES-4). This form MODES-10B should be attached to the MODES-4.
    • Download: Quarterly Wage Report Continuation Sheet* This is an Excel fillable form. For a blank printable form, use the following bullet point.
    • Download the Form - this form is a "print only" form.
• Adjust wage and tax totals or wages of individual workers that were, or should have been, previously reported
  • Internet USTAR <--File Adjustment Request Here
  • Contribution and Wage Adjustment Report (MODES-4A)
    Employers use the Contribution and Wage Adjustment Report to adjust summary total and wage data previously reported. A separate report is to be used for each quarter to be adjusted and for each separate account number assigned.
• Social Security Number Correction (MODES-4427)
  Employers use the Social Security Number Correction form to correct the social security number of an employee whose number was erroneously reported. Employers may correct the social security number of one employee on each correction form, but the form may be applicable to more than one calendar quarter. After making the correction, please return to:
  Division of Employment Security
  Attn: Employer Accounts Unit
  P. O. Box 59
  Jefferson City, MO 65104-0059
  or it can be faxed to 573-751-9705.
• Application for Joint Account(MODES-2241-2) (Microsoft Word format)
• Common Paymaster Law (MODES-4337)
• Common Paymaster Application (MODES-4338)
  The Common Paymaster Application is completed by a business that wishes to report the workers of a related business under its own account number. The Division of Employment Security will use the information provided on the application to either approve or deny the request for Common Paymaster reporting. To qualify:
  1. The businesses involved must be corporations or limited liability companies taxed as corporations.
  2. The entities must be related.
  3. The workers reported by the Common Paymaster must perform service for two or more of the related corporations during each calendar quarter.
• Electronic Reporting
  • Electronic File Transfer and Magnetic Media Reporting Specifications (MODES-INF-368)
    This booklet contains instructions and specifications for electronic file transfer (Internet) or magnetic media reporting (computer diskette or compact disc) to the Missouri Division of Employment Security.
  • Transmittal of Quarterly Wages reported on Magnetic Media (MODES-4260)
    This document is used by employers reporting quarterly contribution and wage information via magnetic media. It lists all the information necessary for the submission and processing of the quarterly magnetic media reports. Effective January 1, 2008, the Division will not accept quarterly unemployment insurance wages on a tape cartridge. Wages may be submitted on the Internet or on a compact disc or 3-1/2 diskette.
• Termination of Coverage Application (MODES-6) (Microsoft Word format)
  This application is to be completed by an employer that would like to request termination of coverage. Please see the form to learn the necessary qualifications for your specific employer type. This form is effective January 1st and must be filed by February 10th of the year with respect to which the termination is to be effective.
• Voluntary Payment Work Sheet (MODES-2272)

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Forms for Lessor Employing Units

• Assignment and Escrow Agreement (MODES-4251)
  Some employers ("lessors") lease employees to clients. Unless the lessor provides a financial guarantee, such as posting securities, to ensure prompt payment of unemployment liabilities: (1) the lessor must file a separate Quarterly Contribution and Wage Report for the employees leased to each client; and (2) the client is jointly liable for the contributions otherwise due on the workers it leases from the lessor. MODES-4251 must be used for the posting of securities.
• Surety Bond (MODES-4252)
  Some employers ("lessors") lease employees to clients. Unless the lessor provides a financial guarantee, such as a surety bond, to ensure prompt payment of unemployment liabilities: (1) the lessor must file a separate Quarterly Contribution and Wage Report for the employees leased to each client; and (2) the client is jointly liable for the contributions otherwise due on the workers it leases from the lessor. MODES-4252 must be used for the posting of a surety bond.
• Lessor Employing Units Regulation (MODES-4281)
• Quarterly Client List (MODES-4282)
  An employer ("lessor") leasing workers to other businesses ("clients") uses the Quarterly Client List to inform the Division of new and former clients. The Division uses the form to maintain responsibility for unemployment tax filing. The Quarterly Client List must be filed by the lessor each quarter per Missouri labor regulations.
• Lessor Employing Unit/Client Lessee Law (MODES-4267)
  The Division of Employment Security may consider an employer who provides, or "leases", employees to another business to be a "lessor employing unit". The business to whom the employees are provided is termed a "client lessee". The Missouri Employment Security Law states that a lessor employing unit will be responsible for reporting all wages paid and be liable for contributions (tax) due on the wages paid.
  1. The lessor employing unit has the option to make a financial guarantee to the Division to pay contributions due. The lessor may guarantee payment by posting and maintaining a surety bond, depositing securities, providing an irrevocable letter of credit, or obtaining a certificate of deposit. This action will relieve the lessor's clients of any liability. It will also allow the lessor to report all employees on one quarterly return.
  2. If the lessor does not make a financial guarantee to the Division that contributions will be paid, the client lessee will be jointly liable for contributions due on wages paid to the employees provided to it. In order to identify the employees provided to each client lessee, the lessor must file a separate quarterly return for each client lessee.
  
  To maintain correct records, the Division requires the lessor to submit a quarterly list of its clients.
  
  NOTE: The above provisions do not apply to private employment agencies who provide their employees to others on a temporary help basis.
  
• Irrevocable Letter Of Credit (MODES-4354)
• Authorization For Release Of Confidential Information (MODES-4354-3)
• Irrevocable Letter Of Credit Regulation (C-248)

Forms for Consumer Directed Services Vendors

• Quarterly CDS Vendor Consumer List (MODES-4590)

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Division of Labor Standards

Wage and Hour

Wage and Hour Forms

• Wages, Hours and Dismissal Rights (LS-18) (size 60k)

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Minimum Wage

Mimimum Wage Forms

• Summary to Post (LS-52)
• Spanish Minimum Wage Summary Poster (LS-52-3)

Minimum Wage Complaint Forms

• Minimum Wage Complaint Form (LS-51)

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Prevailing Wage

Prevailing Wage Forms

• Project Notification - Contractor Information Notification (PW-2) (size 72k)
• Request for Wage Determination (PW-3) (size 91k)
• Affidavit of Compliance with Prevailing Wage Law ( PW-4) (size 57k)
• Missouri Public Work Check-Off List (PW-5) (size 58k)
• Prevailing Wage Complaint Form (PW-6) (size 106k)
• Contractor's Check-Off List (PW-8)(size 71k)
• Contractor's Report of Construction Wage Rates (LS-04) (size 117k)
• Missouri Department of Labor Contractors Payroll Form (LS-57) (size 387K)
• Instruction Sheet for the Contract Payroll Form (LS-57-3) (size 69K)
• Wage Rates for State Highway Construction (General Wage Order No. 53) (size 752k)

Prevailing Wage Brochures

English

• Mo Prevailing Wage Laws (LS-13) (size 47k)
• Labor Provisions for Employees of Construction Contractors (PW-7) (size 49k)

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Youth Employment

Child Labor Publications

• Mo Child Labor Laws (LS-11) (size 100k)
• Chapter 294-Child Labor (LS-15) (size 66k)
• Safety at Work for Young Workers (LS-16) (size 200k)
• Thanks for Staying in School (LS-19) (size 99k)
• Youth in the Workplace - An Employer's Outlook (LS-21) (size 98k)
• Mo Child Labor Bookmark (LS-23) (size 138k)
• Mo Child Labor Law for School Officials (LS-26) (size 102k)
• Children Involved in Youth Peddling Door-to-Door Sales (LS-27) (size 90k)
• Parent's Guide to Child Labor Laws and OJS (LS-28) (size 165k)
• Working Youth in Agriculture (LS-36) (size 104k)
• Entertainment Work Permit (LS-37)
• Frequently Asked Questions About Federal and State Child Labor Laws (Non-Agriculture Employment) (LS-41) (size 124k)
• Youth on the Job - Missouri Laws Protecting Young Workers (LS-56) (size 156k)

Child Labor Forms

• Work Certificate (during school months)
• Work Certificate (full-time - summer)
• Entertainment Work Permit Request (LS-37) (size 87k)
• Employers Employing Workers Under the Age of 16 List (LS-43) (size 42k)
• Submit a child labor complaint (LS-53) (size 95k)

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On-Site Consultation Brochures

• Mo Safety and Health Consultation Service (LS-10) (size 86k)
• Application for Consultation Service Form (LS-25)
• The Safety and Health Achievement Recognition Program (SHARP) (LS-54)(size 160k)
• Workplace Safety and Health Programs (LS-58) (size 87k)

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Mine and Cave Safety - Publications

English

• Mo Mine and Cave Safety and Health Program (LS-14) (size 83k)

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Workers' Safety Program

• Request Assistance from the MWSP (LSWSP-6)
• Register of Safety Consultants and Engineers (*) HTML(size 160k)
• Certification Requirements (size 87k)

Consultants

• Application for Certification - Safety Consultant/Safety Engineer (LSWSP-10-AI)
• Annual Certification Renewal - Safety Consultant/Safety Engineer (LSWSP-11-AI)

Insurance Carriers

• Application for Certification (LSWSP-45-AI)
• Application for Re-Certification (LSWSP-46-AI)

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Division of Workers' Compensation

Required Posters

Brochures

The following booklets may be ordered through the Division of Workers' Compensation. Request must be put in writing with a check or money order enclosed payable to the Division of Workers' Compensation and sent to the Division of Workers' Compensation, P.O. Box 58, Jefferson City, MO 65102-0058 or direct questions to 800-775-2667.

Informational Booklets and Pamphlets for a fee

• Missouri Workers' Compensation Statutes, Chapter 287. $4.00 per copy. See ordering information above.

Free Informational Booklets and Pamphlets

• Facts For Injured Workers (English and Espanol)
• Dispute Management Process
• Missouri's Second Injury Fund
• Workers' Compensation: Fraud and Noncompliance
• Survivors' Benefits: For Family Members of Missouri's Fallen Workforce
• Workers' Compensation Requirements For the Missouri Construction Industry
• Appeals Rights and Procedures Brochure

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Forms

Employers Insurers and Third Party Administrators (TPAs)
Attorneys
Injured Workers
Healthcare Providers
Line of Duty Compensation Benefits
Religious Exception
Physical Rehabilitation
Second Injury Fund Surcharge
Self-Insurance
Tort Victims

Employers Insurers and Third Party Administrators (TPAs)

• EDI & Web-enabled Filings
• Supplemental Reports to be Filed
• Docketing & Adjudication
• Other Forms

EDI & Web-enabled Filings

• Report of Injury (WC-1-EDI)

Electronic Data Interchange (EDI)

• EDI Missouri Specific Requirements
• EDI Service File Transfer Protocol (FTP)
• EDI Project Agreement
• EDI Receivers Specifications - Word Document
• EDI Senders Response - Word Document
• EDI Master Trading Partner Profile
• EDI Sender Trading Partner Profile - List of Insurers - Word Document
• EDI Sender Trading Partner Profile - Word Document
• EDI Missouri Data Dictionary
• EDI File Matrix - Excel Spreadsheet
• EDI Cause of Injury, Nature of Injury and Body Parts Codes (Word Document)
• International Association of Industrial Accident Boards and Commissions

Web Enabled Filings

Supplemental Reports to be Filed

• Notice of Commencement/Termination of Compensation (WC-2) - Excel Spreadsheet
• Medical Treatment Form (WC-9)
• Claim for Compensation (WC-21)
• Answer to Claim For Compensation (WC-22)
• Physicians Report on Eye Injuries (WC-241)

Docketing & Adjudication

Electronic Data Correspondence (Trading Partners) (WC-133)

• The Division now offers a safe, secure, fast way of sending docket notices to our customers. The requirements are easy, download the form, fill it in and email to the Division.
  • Electronic Data Correspondence (Trading Partners) (WC-133) - Word 97/2000 Document
  • Electronic Data Correspondence (Trading Partners) (WC-133)
• Stipulation for Compromise Settlement (WC-G-11-AI)
• Request for Voluntary Conference (WC-182-AI)
• Request for Pre-Hearing (WC-183-AI)
• Request for Mediation (WC-184-AI)

Other Forms

• Disability Schedule and Benefit Limits (WC-110)
• Affidavit of Exemption for Workers' Compensation Insurance (WC-134)
• Authorization to Inspect and/or Copy Medical Records (WC-43-AI)
• Application for Review to the Labor and Industrial Relations Commission (MOIC-2567)
• Noncompliance Referral Form (WC-258)

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Attorneys

• Claim for Compensation (WC-21)
• Answer to Claim For Compensation (WC-22)
• Authorization to Inspect and/or Copy Medical Records (WC-43-AI)
• Disability Schedule and Benefit Limits (WC-110)
• Entry of Appearance (WC-235)
• Motion to Withdraw (WC-236)
• Substitution of Counsel (WC-237)
• Application for Review to the Labor and Industrial Relations Commission (MOIC-2567)
• Stipulation for Compromise Settlement (WC-G-11-AI)
• Request for Voluntary Settlement Conference (WC-182)
• Request for Pre-Hearing (WC-183)
• Request for Mediation (WC-184)
• Request for Hearing-Hardship or Section 287.203 RSMo Hardship Hearing (WC-185)
• Request for Hearing-Final Award (WC-186)
• Application for Review to the Labor and Industrial Relations Commission (MOIC-2567)
• Missouri Docket Map (PDF)
• Docket Locations Directory - Excel Spreadsheet

Medical Fee Disputes

• Application for Direct Payment (WC-MD-01)
• Application for Payment of Additional Reimbursement of Medical Fees (WC-MD-02)
• Application for Evidentiary Hearing (WC-MD-03)
• Request for Dismissal of Application for Payment of Additional Reimbursement of Medical Fees (WC-MD-05)
• Request for Dismissal of Application for Direct Payment (WC-MD-10)
• Request by a Health Care Provider for Case Status Information to file a Medical Fee Dispute Application (WC-194)
• Answer to Application for Payment of Additional Reimbursement of Medical Fees (WC-198)
• Answer to Application for Direct Payment (WC-199)
• Entry of Appearance (WC-200)
• Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-201)
• Health Care Provider's Response to Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-202)
• Application for Administrative Ruling (WC-214)

Forms for Subpoenas

• Workers' Compensation Subpoena (WC-25-AI) (Fillable and Printable)
• Workers' Compensation Subpoena Duces Tecum (WC-25-A-AI) (Fillable and Printable)
• Workers' Compensation Subpoena For Deposition (WC-25-B-AI) (Fillable and Printable)
• Workers' Compensation Subpoena Duces Tecum For Deposition (WC-25-C-AI) (Fillable and Printable)

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Injured Workers

• Authorization to Release Information (WC-126-AI) and Instructions
  • Record Check
• Claim for Compensation (WC-21)
• Request for Voluntary Conference (WC-182-AI)
• Request for Pre-Hearing (WC-183-AI)
• Request for Mediation (WC-184-AI)
• Request for Hardship Hearing and/or Section 287.203 Hardship Hearing (WC-185-AI)
• Request for Hearing-Final Award (WC-186-AI)
• Stipulation for Compromise Settlement (WC-G-11-AI)
• Eligibility Guidelines for Second Injury Rehab Benefits (WCR-7)
  • Physical Rehabilitation
• Claim for Compensation for Line of Duty Compensation Benefits (WCLoD-1-AI)
• Application for Review to the Labor and Industrial Relations Commission (MOIC-2567)
• Noncompliance Referral Form (WC-258)

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Healthcare Providers

Medical Fee Disputes

• Application for Direct Payment (WC-MD-01)
• Application for Payment of Additional Reimbursement of Medical Fees (WC-MD-02)
• Application for Evidentiary Hearing (WC-MD-03)
• Request for Dismissal of Application for Payment of Additional Reimbursement of Medical Fees (WC-MD-05)
• Request for Dismissal of Application for Direct Payment (WC-MD-10)
• Request by a Health Care Provider for Case Status Information to file a Medical Fee Dispute Application (WC-194)
• Answer to Application for Payment of Additional Reimbursement of Medical Fees (WC-198)
• Answer to Application for Direct Payment (WC-199)
• Entry of Appearance (WC-200)
• Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-201)
• Health Care Provider's Response to Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-202)
• Application for Administrative Ruling (WC-214)

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Religious Exception

• Religious Exception Information (WC-138-A)
• Employee's Application for Religious Exception (WC-138)
• Employee's Religious Exception Affidavit and Waiver (WC-138-3)
• Employer's Affidavit for Religious Exception (WC-138-5)
• Religious Exception Application and Affidavit Instructions (WC-138-7)

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Physical Rehabilitation

• Physician's Rehabilitation Information Sheet (WCR-1A)
• Verification of Rehabilitation Treatment (WCR-4A)
• Bi-Weekly Report on Physical Rehabilitation (WCR-5A)
• Report of Serious Injury Referral Form (WCR-6)
• Eligibility Guidelines for Physical Rehabilitation (WCR-7)
• Request for Certification of Rehabilitation Providers (WCR-8)

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Second Injury Fund Surcharge

• Affidavit of Zero Reporting - Commercial Insurers Only (WC-240)
• Memorandum to Commercial Insurers (WC-240-3)

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Self-Insurance

Individual Forms
Application

• Application for Authority to Self-Insure (WC-81)
• Checklist for Individual Self-Insurance Applications (WC-128) - Word Document
• Auditing Procedures for Applicants for Individual Self-Insurance (WC-130-AI)

Security

• Bond of Employer Carrying His Own Risk (WC-82B)
• Escrow Agreement (WC-82E)
• Irrevocable Letter of Credit (WC-249)
• Authorization for Release of Confidential Information (WC-249-3)
• Affidavit for Security Release - Word Document

Miscellaneous

• Statement of Specific and Aggregate Excess Insurance Coverage (WC-121)
• Guaranty to Satisfy Compensation Claims Under Workers’ Compensation Law of Missouri (WC-82A)

Annual Reports

• Individual Self Insured Employer Information Sheet (WC-131)
• Self-Insurer’s Statement of Outstanding Losses (WC-83)
• Self-Insurer’s Payroll Report (WC-84)
• Self-Insurer’s Annual Financial Statement (WC-85)
• Self-Insurer’s Report of Compensation Payments (WC-86)

Group Forms

Trust Application

• Application for Self-Insurance Trust (WC-81A)
• Self-Insured Trust Safety Program Initial Certification Procedures (WC-129-AI)
• Self-Insurance By-Laws - Sample (WC-238)
• Indemnity (Trust) Agreement - Word Document
• Group Insurance Checklist (WC-239)

Member Application

• Application for Membership (WC-81B)

Security

• Bond of Employer Carrying His Own Risk (WC-82B)
• Escrow Agreement (WC-82E)
• Irrevocable Letter of Credit (WC-249)
• Authorization for Release of Confidential Information (WC-249-3)

Trust Annual Reports

• Annual Report/Claim Development Reports (WC-135)

Rate Filing and Surplus Request

• Form for Trust to Submit Proposed Rates (WC-127)
• Form for Trust to Submit to Obtain Authorization to Release Surplus - Word Document

Miscellaneous

• Name and Address Change Form for Self-Insured Trusts - Word Document
• Statement of Specific and Aggregate Excess Insurance Coverage (WC-121)
• Trust Quick Reference Due Dates (WC-193)

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Tort Victims

The Tort Victims’ Compensation Fund exists to help compensate those who have been injured due to the negligence or recklessness of another (such as in a motor vehicle collision or a hunting accident), and who have been unable to obtain full compensation because the part at fault (the “tortfeasor”) had no insurance, or inadequate insurance, or has filed for bankruptcy, or for other reasons specified by the law.

• Application for Tort Victims' Compensation (WCT-1)
• Questions and Affidavit Regarding Benefit Sources and Payments - Affidavit Form A (WCT-2)
• Questions and Affidavit Regarding Lost Income - Affidavit Form B (WCT-3)
• Questions and Affidavit Regarding Waiver of Final Judgment Requirement - Affidavit Form C (WCT-4)
• Questions and Affidavit Regarding Due Diligence in Enforcing the Judgment - Affidavit Form D (WCT-5)
• Questions and Affidavit Regarding Completeness of Medical Information Submitted - Affidavit Form E (WCT-6)

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