For ACH only. From the Missouri Department of Labor and Industrial Relations, Division of Workers' Compensation.

 

This form must be used by the Workers’ Compensation Insurance Carriers, the Self-Insured Employers and the Self-Insured Groups or trusts who would like to make Second Injury Fund surcharge payments beginning in CY 2003 to the Missouri Division of Workers’ Compensation (Division) through an Electronic Fund Transfer. Under the Missouri workers’ compensation law, Chapter 287 RSMo, the surcharge payments are deposited to the credit of the Second Injury Fund. Recipients of this form should bring this information to the attention of their respective financial institution.