Missouri Dining Safety Group Yearly Membership

$75.00 / year

Please complete the membership form below.  Then click the SIGN UP NOW button, and you will be directed to the checkout page to complete payment.

  • Email address for Enrolled Member
  • Date Format: MM slash DD slash YYYY
  • Declaration of Application for Safety Membership Group

    The applicant is a member of the Missouri Dining Safety Group. The applicant agrees to promptly pay all Group Workers’ compensation premium and deposits when billed and due. The applicant understands and agrees that upon failure to pay any outstanding financial obligations due on his/her account to the Insurer, or to maintain Association membership, the Applicant will immediately cease to be a Group Member. The applicant gives the Group Secretary power of attorney to obtain and use, in the interests of the Group or the Individual Member, any information held by the Insurer relating to claims, experience rating, loss prevention services or other information which may be the subject of Group research and inquiry.

    The Applicant understands that:

    Individual Worker’s Compensation policies are considered for issuance to Association members in accordance with applicable rules and regulations, as determined by the insurance carrier. The insurance carrier does not intend to declare dividends respecting the subject of Workers’ Compensation policies. Active participation in the safety activities of the Group is a requirement for continued membership in the Group.

  • Date Format: MM slash DD slash YYYY

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