- Affidavit for Clerical Office Occupation Classification (Workers’ Compensation only) – Clerical support staff may be covered under a different optional class code than those of the main business. This form requests the optional classification for clerical employees. If a company does not have this class code, or if the employee does not meet the definitions of this class, then those wages must be reported under the assigned industry class code.
- Affidavit for Outside Sales Classification (Workers’ Compensation only) – This classification can be used for a worker predominantly engaged in sales or collections work away from the premises of the business, and whose work time spent at the business premises is engaged in sales or collections work which is necessary to their outside sales duties. Workers who are engaged in servicing equipment or delivery of the employer’s product do not qualify for coverage under the Outside Sales occupation classification.
- Affidavit for Inside Sales Classification
- Amended Quarterly Report Instructions
- Amended Summary Report/Wage Listing (Excel) – Use this form when notifying the Division of reporting errors on already submitted Summary Reports or Wage Listings. You may also submit a Workers’ Compensation Certificate of Good Standing online request.
- Corporate Officer Notice of Change Form
- Deductible Program Application Form
- Drug & Alcohol Discount Program Application
- Employers Application for Claims Cost Apportionment – Pursuant to Wyoming Statute §27-14-201(d), the employer may apply to the Division for determination of chargeability of any one of the injuries affecting their Experience Modification Rating (EMR).
- Following the submission of evidence, the Division will review and issue a final determination within 120 days.
- Employer’s Notice of Change Form – Use this document to report changes of address, name, telephone number; addition or change of federal ID number; change of account status; sale of a portion or all of the business. Complete all sections that apply by marking the appropriate choice and providing information as requested, date and sign. Attach documentation as needed.
- Extension of Extra-Territorial Coverage Request
- Information on all Workers’ Compensation Discount Programs
- Instructions – WC Summary Report and Wage Listing – Instruction sheets for filling out the WC Summary Reports and Employee Wage listings.
- Instructions – UI or UI/WC Summary Report and Wage Listing – You can also file your quarterly summary reports electronically by using WYUI
- Out-of-State Employer Questionnaire – Use this form if you are a Non-Resident Employer. This form should be mailed to the Division with the Joint Employer Registration.
- Power of Attorney Form – The Division must have this completed form in order to talk with anyone, other than the company, about the account (i.e.: payroll companies, accountants, etc.)
- Remittance Coupon (Workers’ Compensation only) – Available in Excel
- Companies who wish to submit their Workers’ Compensation premiums on a monthly rather than quarterly basis, may send them in with this form. The Quarterly reports must still be turned in when due. Please make sure the form is completely filled out to ensure proper identification. This form is also to make any type of payments that aren’t being mailed in with a corresponding payroll report such as a Promissory Note or a penalty/interest payment.
- Request a Certificate of Good Standing (For assistance with your user ID or password, email dws-wccert@wyo.gov)
- Safety Discount Program Application
- Student Learner/Student Training Agreements – This program allows for extra-hazardous employers with Workers’ Compensation coverage to enter into a student learner agreement or student training agreement with a school, student, and the Division. Students will be covered under the employer’s Workers’ Compensation policy while gaining real-world experience and school credit or compensation. The employer is responsible for filing the agreement with the Division. If any changes or termination of the agreement occur, the employer is responsible for informing and updating the Division. Please reference Child Labor Requirements and the Wyoming Workers’ Compensation Student Learner Agreements flyer.
- Monthly/Quarterly Corporate Officer Statewide Average Wage
- UI or UI/WC Summary Report – If you need a replacement copy of this form, please contact the Division at (307) 235-3217. If you need additional Wage Listings, you may request them. Click here for instructions for correctly filling out the form. You can also file your quarterly summary reports electronically by using WYUI.
- WC Summary Report (Workers’ Compensation only) – If you need a replacement copy of this form, please contact the Division at (307) 777-6763 or email DWS-wcemployerservices@wyo.gov. Click here for instructions for correctly filling out this form.
Brochures
NON-RESIDENT EMPLOYERS’ SURETY BOND (WORKERS’ COMPENSATION ONLY)
This document must be submitted to the Division for those companies that are not based in Wyoming if wages are more than $4,000/month.
AFFIDAVIT FOR CORPORATE OFFICER COVERAGE (WORKERS’ COMPENSATION ONLY)
This document is no longer available online. Please contact the Division at (307) 777-6763 or email DWS-wcemployerservices@wyo.gov. This affidavit must be completed in order for Corporate Officers to have coverage with Workers’ Compensation. No coverage will be allowed until after this affidavit is received.
AFFIDAVIT FOR LIMITED LIABILITY COMPANY MEMBERS COVERAGE (WORKERS’ COMPENSATION ONLY)
This document is no longer available online. Please contact the Division at (307) 777-6763 or email DWS-wcemployerservices@wyo.gov. This affidavit must be completed in order for LLC Members to have coverage with Workers’ Compensation. No coverage will be allowed until this affidavit is received.
EXPERIENCE MODIFICATION RATES
Employers can use our Workers’ Compensation Claim Experience Modification Rate Impact Calculator (Excel) to determine the years a claim will impact their Experience Modification Rate.
View Guidelines for the North American Industry Classification System (NAICS) Grouping:
North American Industry Classification System Grouping
RAW MATERIALS AND ENERGY PRODUCTION
- Sector 11 – Agriculture, Forestry, Fishing and Hunting
- Sector 21 – Mining
- Sector 22 – Utilities
CONSTRUCTION
- Sector 23 – Construction
MANUFACTURING
- Sector 31-33 – Manufacturing
DISTRIBUTION AND TRANSPORTATION OF GOODS
- Sector 42 – Wholesale Trade
- Sector 44-45 – Retail trade
- Sector 48-49 – Transportation and Warehousing
INFORMATION
- Sector 51 – Information
FINANCE, INSURANCE, REAL ESTATE AND RENTAL AND LEASING
- Sector 52 – Finance and Insurance
- Sector 53 – Real Estate and Rental and Leasing
PROFESSIONAL AND BUSINESS SERVICES
- Sector 54 – Professional, Scientific and Technical Services
- Sector 55 – Management of Companies and Enterprises
- Sector 56 – Administrative and Support, Waste Management and Remediation Services
EDUCATION, HEALTH AND SOCIAL SERVICES
- Sector 61 – Education
- Sector 62 – Health and Social Services
LEISURE, ACCOMMODATION AND FOOD SERVICES
- Sector 71 – Arts, Entertainment and Recreation
- Sector 72 – Accommodation and Food Services
OTHER SERVICES (EXCEPT PUBLIC ADMINISTRATION)
- Sector 81 – Other Services (except Public Administration)
PUBLIC ADMINISTRATION
- Sector 92 – Public Administration