Form WC-304-G "Notice of Employers Election to Become a Member of a Group Insurance Pool Pursuant to 287.200.4(3)(A), Rsmo" - Missouri

What Is Form WC-304-G?

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, 2017;
  • 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;

Download a fillable version of Form WC-304-G 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-304-G "Notice of Employers Election to Become a Member of a Group Insurance Pool Pursuant to 287.200.4(3)(A), Rsmo" - Missouri

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
3315 W. Truman Blvd.
P.O. Box 58
NOTICE OF EMPLOYERS ELECTION TO BECOME A MEMBER
Jefferson City, MO 65102-0058
OF A GROUP INSURANCE POOL* PURSUANT TO
www.labor.mo.gov/DWC
§287.200.4(3)(a), RSMo
_________________________________________________
Name of Employer
I, __________________________________, on behalf of the above named employer, hereby give the
Department of Labor and Industrial Relations, Division of Workers’ Compensation, notice of this employer’s
election to accept mesothelioma liability under the Missouri Workers’ Compensation Law. This election
remains in full force and effect until and unless revoked by the employer.
Employer’s Full Legal Name: ___________________________________________________
Employer’s Address:
___________________________________________________
___________________________________________________
___________________________________________________
Company Contact Name:
___________________________________________________
Title:
___________________________________________________
Phone Number:
___________________________________________________
Email Address:
___________________________________________________
__________________________
__________________________________________________
Date
Signature
__________________________________________________
Printed Name
__________________________________________________
Title
STATE OF MISSOURI
)
)
COUNTY OF
)
Subscribed and sworn to before me this
day of
, 20
My Commission Expires:
Notary Public
(SEAL)
The full text of §287.200, RSMo, can be found online at
http://www.moga.mo.gov/mostatutes/stathtml/28700002001.html
*Such a group shall comply with §287.223, RSMo – “Missouri Mesothelioma Risk Management Fund”
Missouri Division of Workers’ Compensation is an equal opportunity employer/program. Auxiliary aids and services
are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711
WC-304-G (03-17) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
3315 W. Truman Blvd.
P.O. Box 58
NOTICE OF EMPLOYERS ELECTION TO BECOME A MEMBER
Jefferson City, MO 65102-0058
OF A GROUP INSURANCE POOL* PURSUANT TO
www.labor.mo.gov/DWC
§287.200.4(3)(a), RSMo
_________________________________________________
Name of Employer
I, __________________________________, on behalf of the above named employer, hereby give the
Department of Labor and Industrial Relations, Division of Workers’ Compensation, notice of this employer’s
election to accept mesothelioma liability under the Missouri Workers’ Compensation Law. This election
remains in full force and effect until and unless revoked by the employer.
Employer’s Full Legal Name: ___________________________________________________
Employer’s Address:
___________________________________________________
___________________________________________________
___________________________________________________
Company Contact Name:
___________________________________________________
Title:
___________________________________________________
Phone Number:
___________________________________________________
Email Address:
___________________________________________________
__________________________
__________________________________________________
Date
Signature
__________________________________________________
Printed Name
__________________________________________________
Title
STATE OF MISSOURI
)
)
COUNTY OF
)
Subscribed and sworn to before me this
day of
, 20
My Commission Expires:
Notary Public
(SEAL)
The full text of §287.200, RSMo, can be found online at
http://www.moga.mo.gov/mostatutes/stathtml/28700002001.html
*Such a group shall comply with §287.223, RSMo – “Missouri Mesothelioma Risk Management Fund”
Missouri Division of Workers’ Compensation is an equal opportunity employer/program. Auxiliary aids and services
are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711
WC-304-G (03-17) AI