Form WC-85 "Self-insurer's Annual Financial Statement" - Missouri

What Is Form WC-85?

This is a legal form that was released by the Missouri Department of Labor and Industrial Relations - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2011;
  • The latest edition provided by the Missouri Department of Labor and Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC-85 by clicking the link below or browse more documents and templates provided by the Missouri Department of Labor and Industrial Relations.

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Download Form WC-85 "Self-insurer's Annual Financial Statement" - Missouri

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd.
P.O. Box 58
Jefferson City, MO 65102-0058
573-751-4231
www.labor.mo.gov/DWC
IT IS REQUIRED THAT THE FINANCIAL STATEMENT BE FOR THE SELF-INSURED ENTITY ONLY AND SHALL BE EXECUTED ON THIS FORM. ALL FINANCIAL
INFORMATION MUST BE AUDITED. YOU MAY ATTACH AN ANNUAL REPORT OR AUDITED INTERNAL FINANCIAL STATEMENT WITH ACCOUNT DETAILS. HOWEVER,
SUMMARY FIGURES MUST BE ON THIS REPORT. FINANCIAL STATEMENTS FOR THE PARENT MAY NOT BE SUBSTITUTED FOR THE SUBSIDIARY’S INDIVIDUAL FINANCIAL
INFORMATION UNLESS PRIOR APPROVAL HAS BEEN GIVEN BY THE DIVISION.
Self-Insurer’s
Annual Financial Statement
This is a confidential report to the Division of Workers’ Compensation for the purpose of showing financial ability to pay worker’s compensation liabilities as a
self-insurer under Section 287.280 Workers’ Compensation Law
Employer Name _______________________________________________ Employer Address _________________________________________
_________________________________________
Fiscal Year Ending _________________________________________
Figures are in
_________________________________________
(Denomination)
Name of Auditing Firm or Individual _____________________________________________
Assets
Current Assets
Cash and Cash Equivalents. . . . . . . . . . . . . . . . . .
$_______________________
Short Term Investments . . . . . . . . . . . . . . . . . . . .
$_______________________
Notes Receivable Net (less discount) . . . . . . . . . .
$_______________________
Accounts Receivable Net . . . . . . . . . . . . . . . . . . .
$_______________________
Inventory (itemized or enter total on this form and attach detail)
________________________________
________________________________
________________________________
________________________________
________________________________
Total Inventory . . . . . . . . . . . . . . . . . . .
$_______________________
Deferred Income Taxes. . . . . . . . . . . . . . . . . . . . .
$_______________________
Other Current Assets (itemized or enter total on this form and attach detail)
________________________________
________________________________
________________________________
________________________________
________________________________
Total Other Assets. . . . . . . . . . . . . . . . .
$_______________________
Total Current Assets
$_______________________
Long-Term Assets
Fixed Assets Net of Depreciation (itemized or enter total on this form and attach detail)
________________________________
________________________________
________________________________
________________________________
________________________________
Total Fixed Assets. . . . . . . . . . . . . . . . .
$_______________________
Deferred Assets . . . . . . . . . . . . . . . . . . . . . . . . . . .
$_______________________
Intangible Assets/Goodwill Net of Amortization .
$_______________________
Other Assets (itemized or enter total on this form and attach detail)
________________________________
________________________________
________________________________
________________________________
________________________________
Total Other Assets. . . . . . . . . . . . . . . . .
$_______________________
Total Long Term Assets
$_______________________
TOTAL ASSETS
$ ______________________
______________________
WC-85 (10-11) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd.
P.O. Box 58
Jefferson City, MO 65102-0058
573-751-4231
www.labor.mo.gov/DWC
IT IS REQUIRED THAT THE FINANCIAL STATEMENT BE FOR THE SELF-INSURED ENTITY ONLY AND SHALL BE EXECUTED ON THIS FORM. ALL FINANCIAL
INFORMATION MUST BE AUDITED. YOU MAY ATTACH AN ANNUAL REPORT OR AUDITED INTERNAL FINANCIAL STATEMENT WITH ACCOUNT DETAILS. HOWEVER,
SUMMARY FIGURES MUST BE ON THIS REPORT. FINANCIAL STATEMENTS FOR THE PARENT MAY NOT BE SUBSTITUTED FOR THE SUBSIDIARY’S INDIVIDUAL FINANCIAL
INFORMATION UNLESS PRIOR APPROVAL HAS BEEN GIVEN BY THE DIVISION.
Self-Insurer’s
Annual Financial Statement
This is a confidential report to the Division of Workers’ Compensation for the purpose of showing financial ability to pay worker’s compensation liabilities as a
self-insurer under Section 287.280 Workers’ Compensation Law
Employer Name _______________________________________________ Employer Address _________________________________________
_________________________________________
Fiscal Year Ending _________________________________________
Figures are in
_________________________________________
(Denomination)
Name of Auditing Firm or Individual _____________________________________________
Assets
Current Assets
Cash and Cash Equivalents. . . . . . . . . . . . . . . . . .
$_______________________
Short Term Investments . . . . . . . . . . . . . . . . . . . .
$_______________________
Notes Receivable Net (less discount) . . . . . . . . . .
$_______________________
Accounts Receivable Net . . . . . . . . . . . . . . . . . . .
$_______________________
Inventory (itemized or enter total on this form and attach detail)
________________________________
________________________________
________________________________
________________________________
________________________________
Total Inventory . . . . . . . . . . . . . . . . . . .
$_______________________
Deferred Income Taxes. . . . . . . . . . . . . . . . . . . . .
$_______________________
Other Current Assets (itemized or enter total on this form and attach detail)
________________________________
________________________________
________________________________
________________________________
________________________________
Total Other Assets. . . . . . . . . . . . . . . . .
$_______________________
Total Current Assets
$_______________________
Long-Term Assets
Fixed Assets Net of Depreciation (itemized or enter total on this form and attach detail)
________________________________
________________________________
________________________________
________________________________
________________________________
Total Fixed Assets. . . . . . . . . . . . . . . . .
$_______________________
Deferred Assets . . . . . . . . . . . . . . . . . . . . . . . . . . .
$_______________________
Intangible Assets/Goodwill Net of Amortization .
$_______________________
Other Assets (itemized or enter total on this form and attach detail)
________________________________
________________________________
________________________________
________________________________
________________________________
Total Other Assets. . . . . . . . . . . . . . . . .
$_______________________
Total Long Term Assets
$_______________________
TOTAL ASSETS
$ ______________________
______________________
WC-85 (10-11) AI
Liabilities and Net Worth
Current Liabilities
Accounts Payable . . . . . . . . . . . . . . . . . . . . . . . . .
$_______________________
Accrued Liabilities . . . . . . . . . . . . . . . . . . . . . . . .
$_______________________
Other Current Liabilities (itemized or enter total on this form and attach detail)
________________________________
________________________________
________________________________
________________________________
________________________________
Total Other Liabilities. . . . . . . . . . . . . .
$_______________________
Total Current Liabilities
$_______________________
Long-Term Liabilities
Long Term Debt . . . . . . . . . . . . . . . . . . . . . . . . . .
$_______________________
Deferred Income Taxes. . . . . . . . . . . . . . . . . . . . .
$_______________________
Other Long Term Liabilities (itemized or enter total on this form and attach detail)
________________________________
________________________________
________________________________
________________________________
________________________________
Total Other LT Liabilities . . . . . . . . . . .
$_______________________
Total Long Term Liabilities
$_______________________
TOTAL LIABILITIES
$_______________________
Net Worth
Itemize net Worth or enter total on this form and attach detail
________________________________
________________________________
________________________________
TOTAL NET WORTH
$_______________________
TOTAL LIABILITIES AND NET WORTH
$ ______________________
______________________
Total Revenues
_______________________________
Net Income __________________________________
Name of Officers
President
_________________________________
Vice-President ________________________________
Treasurer
_________________________________
Secretary ____________________________________
STATE OF __________________________________
}
SS
COUNTY OF _______________________________
________________________________________________ , being duly sworn, says that he/she is the ___________________________________
of the above-named employer, self-insured pursuant to Section 287.280 of the Missouri Workers’ Compensation Law, that he/she has carefully
examined the foregoing report and the facts therein set forth are true; that the assets are correctly set forth and there are not other liabilities against
the employer than those set forth therein; that it is a report of the self-insured employer, exclusive of subsidiaries or affiliates.
___________________________________________________
Sworn to before me, this _______ day of _________________, ______
(Signature)
NOTE – If the employer is a corporation, signature should be made and
seal used according to the laws of Missouri and the official taking this
_________________________________________________________
(Notary Public)
acknowledgment is cautioned to see that it is properly taken. Do not omit
official title of affiants, if corporation.
(My commission expires _____________________________________)
WC-85-2 (10-11) AI
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