Authorization For Release Of Confidential Information {WC-249-3}

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION I hereby authorize the Missouri Department of Labor and Industrial Relations, Division of Workers' Compensation, to release confidential information to ____________________________________________________ for the purpose of making demand for payment on letter of credit number __________________________________________ as long as the obligation remains in force and effect. Release of this information to the named banking institution does not give the banking institution authority to request information other than information concerning the delinquent periods for which a demand for payment is being made. I also release the Missouri Department of Labor and Industrial Relations, Division of Workers' Compensation, and Division personnel from any and all liability under section 287.380, RSMo, resulting from the release and disclosure of confidential information to this banking institution. In witness whereof I, (We) have duly executed the foregoing this ___________________________________ day of ___________________________ , 20______ . _________________________________________________________________________________________________________ Applicant Typed and Printed _________________________________________________________________________________________________________ Workers' Compensation Account Number _________________________________________________________________________________________________________ Owner/Officer Signature _________________________________________________________________________________________________________ Name and Title Typed and Printed Before me personally appeared _______________________________________________ who acknowledges that s/he signed the foregoing as his/her free act and deed. I have hereunto set my hand and affixed my official seal at my office in this ___________________________ day of ___________________________ , 20______ . My term expires ____________________________ _________________________________________________________ Notary Public WC-249-3 (04-12) AI www.FormsWorkflow.com