Forms & Documents

For Use by Employers/Businesses

  • Information on all Discount Pograms
  • Deductible Program Application Form
  • Amended Summary Reports and Wage Listing
  • Amended Summary Report
  • Amended Wage Listing - Use this form when notifying the Division of reporting errors on already submitted Summary Reports or Wage Listings.
  • 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 - 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.).
  • Certificate of Good Standing - Certificates must be requested in written form. This form can be filled out with the required information and mailed or faxed in. Or you may submit an Unemployment Insurance Certificate Only - online request or Workers' Compensation Certificate Only - online request. Instructions for Workers Compensation Certificate.
  • Request for Certificates of Good Standing Form
  • Employer's Notice of Change - 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 - 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 WIRE
  • 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 $10,000/month
  • Affidavit for Corporate Officer Coverage (Workers' Compensation only) - This document is no longer available online. Please contact the Division at (307) 777-6763. You are NOT eligible for this coverage unless you have regular employees. 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. You are NOT eligible for this coverage unless you have regular employees. 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.
  • 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.
  • 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.
  • 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. Instructions for correctly filling out the form. You can also file your quarterly summary reports electronically by using WIRE.
  • WC Summary Report (Workers' Compensation only) - If you need a replacement copy of this forms, please contact the Division at (307) 777-6763. Instructions for correctly filling out this form.
  • Drug-Free Workplace Premium Credit Program - 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. Annual Application for the Certification of the Drug-Free Workplace Premium Credit Program