For Use by Employers/Businesses

Affidavit for Clerical Office Occupation Classification (Workers’ Compensation only) – Clerical support staff may be covered under a different class code than those of the main business. This form requests that classification. If a company does not have this class code, or if the employee do not meet the definitions of this class, then those wages must be reported under normal class code.

Affidavit for Outside Sales Classification (Workers’ Compensation Only) – 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.

Amended Quarterly Report Instructions (PDF)

Amended Summary Report/Wage Listing (Microsoft Excel) – Use this form when notifying the Division of reporting errors on already submitted Summary Reports or Wage Listings

You may also submit Workers’ Compensation Certificate of Good Standing online request.

Deductible Program Application Form (PDF)

Drug & Alcohol Discount Program Application – Qualifying employers with a Drug and Alcohol Policy can receive a discount off their base rate. If approved, the discount will be effective the next quarter in which all necessary requirements are met. The application must be submitted each year for discount continuation. For additional information, please contact the Division at (307) 777-6763 or email BusinessRisk@wyo.gov. Please click here.

Employers Application for Claims Cost Apportionment 

Employer’s Notice of Change Form (PDF) – 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 below. Attach documentation as needed.

Extension of Extra-Territorial Coverage Request

Information on all Workers’ Compensation Discount Programs (PDF)

Instructions – WC Summary Report and Wage Listing (PDF) – Instruction sheets for filling out the WC Summary Reports and Employee Wage listings.

Instructions – UI or UI/WC Summary Report and Wage Listing (PDF) – You can also file your quarterly summary reports electronically by using WYUI

Notice of Corporate Officer Changes Form (PDF)

Out-of-State Employer Questionnaire (PDF) – 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 (PDF) – 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 or PDF

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 

Safety Discount Program Application – Employers willing to adopt a written health and safety program, with specific requirements, may enroll in the Safety Discount Program to receive a discount off their base rate. Employers must complete an initial application and submit their written safety program for approval. The application must be submitted each year for discount continuation. For additional information, please contact the Division at (307) 777-6763 or email BusinessRisk@wyo.gov. Please click here for information on other discounts available to employers.

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 forms, please contact the Division at (307) 777-6763 or email DWS-wcemployerservices@wyo.govClick here for instructions for correctly filling out this form.

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.

For use by Employees/Injured Workers

Application for Death Benefits (PDF)

Application for Temporary Total Disability Benefits (PDF)

Application for Temporary Total Disability Benefits-Extraordinary Circumstances (PDF)

Change of Address Form (PDF)

IRS W-9

Light Duty Agreement (PDF)

Release of Information Form (PDF)

Request for Change of Health Care Provider (PDF)

Request for Reimbursement (PDF)

Direct Deposit Registration Instructions (PDF)

Wyoming Report of Injury Form (PDF)

Brochures

Employee’s Guide to Reporting an Injury

Employer’s Guide to Reporting An Employee Injury

Indicators of Fraud

Injured Workers

ReliaCard® Information

Enrollment Form 1 (PDF)

Enrollment Form 2 (PDF)

Frequently Asked Questions (PDF)