Form W.c.u.11 - Non-Resident Employers' Surety Bond printable pdf download

W.C.U. 11 (12/07)

Bond Number: _____________________

STATE OF WYOMING

DEPARTMENT OF EMPLOYMENT

Non-Resident Employers' Surety Bond

GIVEN IN LIEU OF DEPOSIT OF CASH OR OTHER SECURITY

UNDER THE WORKERS' COMPENSATION ACT AND

THE LABOR STANDARDS ACT

KNOW ALL MEN BY THESE PRESENTS:

That we, ___________________________________________________________________________________

(Name and Address of Principals)

___________________________________________________________________________________________

as principals and _____________________________________________________________________________

(Name and Address of Surety)

___________________________________________________________________________________________

as surety, are held and firmly bound into THE STATE OF WYOMING, in the full and just sum

of________________________________________________, ($________________________) Dollars, lawful

[Minimum legal requirement Eleven Thousand Dollars ($11,000.00)]

money of the United States of America, to be paid to the State of Wyoming for the use and benefit of the Workers'

Compensation Fund or to insure payment of wages or both in the State of Wyoming.

WHEREAS, the undersigned principal is a non-resident employer of the State of Wyoming, and is about to engage

in the performance of certain business activities, in the State of Wyoming requiring the use or employment and

payment of wages to workers in extrahazardous and/or non-extrahazardous occupations as defined by the Wyoming

Workers' Compensation Act, to-wit:

___________________________________________________________________________________________

(Describe type of operations and amount of anticipated monthly payroll)

___________________________________________________________________________________________

And WHEREAS, said principal recognizes this bond is given only for the coverage by law pertaining to the work,

job or contract above described, and agrees in the event of taking other jobs or contracts in the State of Wyoming to

immediately advise in writing the office of the Department of Employment, Workers’ Safety & Compensation, 1510

East Pershing Blvd, Cheyenne, Wyoming, 82002, of such fact, the location and amount thereof; it being understood

by the principal hereto that should the combined jobs or contracts be in excess of the amount covered by this bond,

then additional bonds must be filed in compliance with provisions of the Workers' Compensation Act and the Non-

Resident Employer's Bond Law, as amended.

NOW, THEREFORE, the condition of this obligation is such that if the principal shall promptly pay and reimburse

the Department of Employment, Workers’ Safety & Compensation, as and when required by the Department of

Employment, State of Wyoming, any and all premiums and penalties due the Division and promptly pays to the

principal's employees all wages payable by the principal in the State of Wyoming in connection with the above

described work, at the end of twenty four (24) months after the date upon which this instrument was received by the

Department of Employment, the latter date to be determined by Department of Employment, then this obligation

shall be void.

Form W.c.u.11 - Non-Resident Employers' Surety Bond