Form WC-249-3 "Authorization for Release of Confidential Information" - Missouri

What Is Form WC-249-3?

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 April 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-249-3 by clicking the link below or browse more documents and templates provided by the Missouri Department of Labor and Industrial Relations.

ADVERTISEMENT
ADVERTISEMENT

Download Form WC-249-3 "Authorization for Release of Confidential Information" - Missouri

Download PDF

Fill PDF online

Rate (4.4 / 5) 73 votes
Page background image
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
I hereby authorize the Missouri Department of Labor and Industrial Relations, Division of Workers’ Compensation, to
release confidential information to ____________________________________________________ for the purpose
of making demand for payment on letter of credit number __________________________________________ as long
as the obligation remains in force and effect. Release of this information to the named banking institution does not give
the banking institution authority to request information other than information concerning the delinquent periods for
which a demand for payment is being made. I also release the Missouri Department of Labor and Industrial Relations,
Division of Workers’ Compensation, and Division personnel from any and all liability under section 287.380, RSMo,
resulting from the release and disclosure of confidential information to this banking institution.
In witness whereof I, (We) have duly executed the foregoing this ___________________________________ day
of ___________________________ , 20______ .
_________________________________________________________________________________________________________
Applicant
Typed and Printed
_________________________________________________________________________________________________________
Workers’ Compensation Account Number
_________________________________________________________________________________________________________
Owner/Officer
Signature
_________________________________________________________________________________________________________
Name and Title
Typed and Printed
Before me personally appeared _______________________________________________ who acknowledges that
s/he signed the foregoing as his/her free act and deed.
I have hereunto set my hand and affixed my official seal at my office in this ___________________________ day
of ___________________________ , 20______ .
My term expires
____________________________
_________________________________________________________
Notary Public
WC-249-3 (04-12) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
I hereby authorize the Missouri Department of Labor and Industrial Relations, Division of Workers’ Compensation, to
release confidential information to ____________________________________________________ for the purpose
of making demand for payment on letter of credit number __________________________________________ as long
as the obligation remains in force and effect. Release of this information to the named banking institution does not give
the banking institution authority to request information other than information concerning the delinquent periods for
which a demand for payment is being made. I also release the Missouri Department of Labor and Industrial Relations,
Division of Workers’ Compensation, and Division personnel from any and all liability under section 287.380, RSMo,
resulting from the release and disclosure of confidential information to this banking institution.
In witness whereof I, (We) have duly executed the foregoing this ___________________________________ day
of ___________________________ , 20______ .
_________________________________________________________________________________________________________
Applicant
Typed and Printed
_________________________________________________________________________________________________________
Workers’ Compensation Account Number
_________________________________________________________________________________________________________
Owner/Officer
Signature
_________________________________________________________________________________________________________
Name and Title
Typed and Printed
Before me personally appeared _______________________________________________ who acknowledges that
s/he signed the foregoing as his/her free act and deed.
I have hereunto set my hand and affixed my official seal at my office in this ___________________________ day
of ___________________________ , 20______ .
My term expires
____________________________
_________________________________________________________
Notary Public
WC-249-3 (04-12) AI