Group Trust Member Information Update {WC-270}

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS GROUP TRUST MEMBER INFORMATION UPDATE 3315 W. Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC Group Trust Name Member Name Group Trust Acronym d.b.a. A change of address or ownership must be provided to the division within thirty (30) days of the change. 8 CSR 50-3.010(6)(A)10. CHANGE IN: Name FEIN Address d.b.a. Primary or Mailing Address Change From: ________________________________ ________________________________ ________________________________ ________________________________ Change To: ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ ADD: CHANGE IN: Name FEIN Address d.b.a. Primary or Mailing Address Change From: ________________________________ ________________________________ ________________________________ ________________________________ Change To: ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ ADD: FEIN Address d.b.a. ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ FEIN Address d.b.a. ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ REMOVE: FEIN Address d.b.a. ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ REMOVE: FEIN Address d.b.a. ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ ADDITIONAL NOTES: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ WC-270 (03-12) AI American LegalNet, Inc. www.FormsWorkFlow.com