Form WC-240 "Affidavit of Zero Reporting - Commercial Insurers Only" - Missouri

What Is Form WC-240?

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 March 1, 2012;
  • 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-240 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-240 "Affidavit of Zero Reporting - Commercial Insurers Only" - Missouri

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3315 West Truman Blvd.
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
P.O. Box 58
AFFIDAVIT OF ZERO REPORTING –
Jefferson City, MO 65102-0058
COMMERCIAL INSURERS ONLY
www.labor.mo.gov/DWC
FOR CALENDAR YEAR
Company Name, Address and NAIC #:
Company Contact, Phone Number and E-mail Address:
Name of President/Executive Officer
Name of Person Completing Affidavit/Title
Before me, the undersigned authority, personally appeared
who,
being duly sworn on oath stated that: I am the President/Executive Officer or
the Person Completing the Affidavit (if different from the President/Executive Officer) respectively of the
and I am of sound mind, capable of making this affidavit and
(Name of Employer)
acquainted with the facts herein stated. The company is reporting zero Second Injury Fund Surcharge due pursuant to
Section 287.715, RSMo et seq. for the calendar year
. This is based upon the fact that the company had no
Missouri direct written workers’ compensation premiums to date for the calendar year in question. If during the course
of the calendar year the direct written workers’ compensation premiums become something other than zero, the company
will begin remitting the appropriate Second Injury Fund Surcharge forms and payments.
Signature of President/Executive Officer
Signature of Person Completing Affidavit
Notary Public Embosser or
State of
County (Or City of St. Louis)
Black Ink Rubber Stamp Seal
Subscribed and Sworn Before Me, This
Use Rubber Stamp in Clear Area Below
Day Of
Year
Notary Public Signature
My Commission Expires
Notary Public Name (Typed or Printed)
WC-240 (03-12) AI
3315 West Truman Blvd.
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
P.O. Box 58
AFFIDAVIT OF ZERO REPORTING –
Jefferson City, MO 65102-0058
COMMERCIAL INSURERS ONLY
www.labor.mo.gov/DWC
FOR CALENDAR YEAR
Company Name, Address and NAIC #:
Company Contact, Phone Number and E-mail Address:
Name of President/Executive Officer
Name of Person Completing Affidavit/Title
Before me, the undersigned authority, personally appeared
who,
being duly sworn on oath stated that: I am the President/Executive Officer or
the Person Completing the Affidavit (if different from the President/Executive Officer) respectively of the
and I am of sound mind, capable of making this affidavit and
(Name of Employer)
acquainted with the facts herein stated. The company is reporting zero Second Injury Fund Surcharge due pursuant to
Section 287.715, RSMo et seq. for the calendar year
. This is based upon the fact that the company had no
Missouri direct written workers’ compensation premiums to date for the calendar year in question. If during the course
of the calendar year the direct written workers’ compensation premiums become something other than zero, the company
will begin remitting the appropriate Second Injury Fund Surcharge forms and payments.
Signature of President/Executive Officer
Signature of Person Completing Affidavit
Notary Public Embosser or
State of
County (Or City of St. Louis)
Black Ink Rubber Stamp Seal
Subscribed and Sworn Before Me, This
Use Rubber Stamp in Clear Area Below
Day Of
Year
Notary Public Signature
My Commission Expires
Notary Public Name (Typed or Printed)
WC-240 (03-12) AI