Form Wc-126 (04-02) - Authorization To Release Information
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2MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
AUTHORIZATION TO RELEASE INFORMATION
EMPLOYER: You must sign and date the statement below or this form will be returned to you.
I hereby certify the information being sought by this request is being made on applicants for employment only after a conditional
job offer has been made, or on current employees for a purpose which is job-related and consistent with business necessity. I further
certify the information obtained in this request will not be used to discriminate in any manner against the individual who is the subject
of this request on the basis to disability, in violation of the Americans with Disabilities Act of 1990. 42 U.S.C. §12101 et seq.
Employer’s Signature
Date
To be completed by EMPLOYER:
(Black ink only or 10 pitch font or greater)
Employer’s Full Name
Employer’s FEIN
Employer’s Street Address
Employer’s City, State, Zip Code
EMPLOYEE: For you to release this information with this form, you must be an employee or have received an offer of
employment.
I hereby voluntarily authorize the Missouri Division of Workers’ Compensation to release information to my employer. The
information to be released shall only include information generated by computer search and shall not include any copies of
documents which may be in the Division’s possession. I understand this authorization will include release of information covering
both pending and closed cases involving any work related injuries on file with the Division.
Employee’s Signature
Date
To be completed by EMPLOYEE:
(Black ink only or 10 pitch font or greater)
Employee’s Full Name
Employee’s Social Security Number
Employee’s Street Address
Employee’s City, State, Zip Code
Subscribed and sworn before me, by __________________________________ (employee) in my presence, this ________ day of
__________________, ______, a Notary Public in and for the State of Missouri.
My Notary Commission expires __________________, ______.
__________________________________
(Signature of Notary Public)
DIVISION OF WORKERS’ COMPENSATION RECORD SEARCH
Submit form and fee to:
If you have questions,
PO BOX 58
call 1-888-837-6069
JEFFERSON CITY, MO 65102-0058
DIVISION DOES NOT ACCEPT FAXES
The information provided pursuant to this request is not to be used in a manner which would violate the Americans with Disabilities Act (ADA).
For more information about the Americans with Disabilities Act (ADA), contact the ADA Project-UMC, Region VII DBTAC, 100 Corporate Lake
Drive, Columbia, MO 65203 or call 1-800-949-4ADA (4232).
WC-126 (04-02) AI
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