Form Wc-126 (04-02) - Authorization To Release Information (Page 2 of 2) in pdf

NOTICE TO EMPLOYERS

WORKERS’ COMPENSATION RECORDS CHECK

The Division of Workers’ Compensation release authorization shall be used by your company to obtain workers’ compensation

records. WC-126 Authorization to Release Information must be used to submit your request. You may submit the original or a copy

of Form WC-126. The request must be mailed or delivered to the Division of Workers’ Compensation at the address below. The

Division does not accept fax filings.

Specific instructions (The Division will reject the request if it does not comply with the following):

1. Both the employer and employee MUST complete the form.

2. Full name (printed or typed). MUST complete form in black ink or minimum of 10-pitch font. If the person’s

name has changed within the last ten (10) years, include prior name(s) along with current name.

3. Employee must sign form and the signature must be properly notarized. The notary seal on the document must be a

black ink rubber stamp with the words “notary seal”, “notary public”, and “State of Missouri”. A notarized signature

by a Notary Public commissioned in another state is acceptable as long as he or she meets the requirements of that

state.

4. Social Security Number must be included and must be legible.

5. Employer Federal Employee Identification Number (FEIN) must be provided.

6. MUST enclose a self-addressed, stamped envelope for return information.

7. Records search fee – $5.00 per individual.

8. Signature date of employee and notary must match and be within 60 days of the date of the request.

9. When ten (10) or more forms are sent at one time, include a legible list of employees’ names, in alphabetical order,

along with their social security number.

10. Forms that are illegible and cannot be reproduced in the Division’s image system will be returned.

Records are searched from January 1986 through present. If a search is requested for records prior to 1986, past employers’ names are

required. A computer printout will be sent for records from January 1986 through present, for no additional charge.

The request must be accompanied by payment. NO CASH. We will accept a company check or money order made payable to:

DIVISION OF WORKERS’ COMPENSATION.

The request and fee must be mailed to:

Division of Workers’ Compensation Record Search

Post Office Box 58

Jefferson City, Missouri 65102-0058

1-888-837-6069

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 ADA, you may contact the ADA Project-UMV, Region VII DBTAC, 100 Corporate Lake

Drive, Columbia, Missouri 65203 or call 1-800-949-4ADA (4232).

Please do not contact the ADA Project with questions about this form or send the form to them.

WC-126-2 AI

Form Wc-126 (04-02) - Authorization To Release Information Page 2