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 Summary Report/Wage Listing (Excel Spreasheet; Download your copy) – Use this form when notifying the Division of reporting errors on already submitted Summary Reports or Wage Listings
Drug & Alcohol Discount Program Application – Qualifying employers with a Drug and Alcohol Policy can apply a discount to 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 discount renewal without policy changes, please click here.
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.
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
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.)
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.
- For assistance with your user ID or password, email email@example.com
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 discount renewal without policy changes, please click here.
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.
Effective July 1, 2021, as a result of HB0239, 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. The Student Learner / Student Training Agreements can be found here. Please complete and follow the submission instructions on the last page.
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 DWSfirstname.lastname@example.org. Click 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 DWSemail@example.com. 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 DWSfirstname.lastname@example.org. 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
Change of Address Form (PDF)
Light Duty Agreement (PDF)
Reimbursement Voucher (PDF)
Enrollment Form (PDF)