Employers Affidavit Of Exception From Workers Compensation Benefits {WC-138-5} | Pdf Fpdf Doc Docx | Missouri

 Missouri   Workers Comp 
Employers Affidavit Of Exception From Workers Compensation Benefits {WC-138-5} | Pdf Fpdf Doc Docx | Missouri

Last updated: 8/11/2012

Employers Affidavit Of Exception From Workers Compensation Benefits {WC-138-5}

Start Your Free Trial $ 13.99
200 Ratings
What you get:
  • Instant access to fillable Microsoft Word or PDF forms.
  • Minimize the risk of using outdated forms and eliminate rejected fillings.
  • Largest forms database in the USA with more than 80,000 federal, state and agency forms.
  • Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
  • Trusted by 1,000s of Attorneys and Legal Professionals


MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS Form 3 of 3 EMPLOYER'S AFFIDAVIT OF EXCEPTION FROM WORKERS' COMPENSATION BENEFITS TO BE FILED WITH THE §287.804 ­ Application for Religious Exception Name of Employer Mailing Address ­ Street City County State Employer's Business Name Federal Employer Identification No. Phone Number ZIP Code (9-Digit) Before me, the undersigned authority, personally appeared sworn on this oath states as follows: who, being duly (Name of Employer) My name is . I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated. I certify that I am the employer of (Employee's Name) . a construction industry employer. . Its established (Name of recognized religious sect or division) Check one: I am I am not I do hereby state that I am a member of tenets and/or teachings conscientiously oppose member acceptance of any private or public insurance benefits which makes payments in the event of death, disability, old age, retirement or towards the cost of medical bills and provision of services for medical bills (including the benefits of any insurance system established by the Federal Social Security Act, 42 U.S.C. 301 to 42 U.S.C. 1397jj), and I adhere to said tenets and/or teachings. I have reviewed this affidavit and to the best of my knowledge and belief, it is true and correct. I understand that providing false and fraudulent information on this affidavit would be subject to investigation by the Division's Fraud & Noncompliance Unit and possible prosecution pursuant to §287.128 RSMo or other applicable laws. STATE OF MISSOURI COUNTY OF Subscribed and affirmed to before me this day of My Commission Expires: ) ) ) Signature of Employer and Date , 20 . Notary Public (Notarial Seal) WC-138-5 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com

Related forms

Our Products