Report Of Injury Instructions Form - State Of Wyoming Department Of Employment Workers' Safety And Compensation Division

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R
I
STATE OF WYOMING
1510 East Pershing Blvd.
EPORT OF
NJURY
D
E
P.O. Box 20207
EPARTMENT OF
MPLOYMENT
I
Cheyenne, WY 82003-7005
Workers’ Safety and
NSTRUCTIONS
Toll Free 1 (800) 870-8883
Compensation Division
REPORTING TIMEFRAMES
Under Wyoming law, you must notify your employer of your injury within 72-hours after an accident or when
the general nature of the injury became apparent.
You must file a Report of Injury with Workers’ Safety and Compensation within 10 days after an accident or
when you became aware of the problem.
HOW TO SUBMIT YOUR REPORT OF INJURY
Mail the completed SIGNED form to: P.O. Box 20207, Cheyenne, WY 82003-7005
INSTRUCTIONS FOR COMPLETING THE INJURY REPORT (for assistance, call 1 (800) 870-8883 or 1 (307) 777-5476)
All sections must be completed. A case number is assigned once the Division receives the completed injury
report.
No decision can be made on the Report of Injury until all required information is received.
Be sure to sign and date the appropriate sections.
EMPLOYER INFORMATION
1. Enter the company’s Official business
1
1.
2.
name as it is stated on the letterhead
or pay check. Do not abbreviate.
2.
Enter the company’s Workers’
Compensation Employer Number.
EMPLOYEE INFORMATION
1.
1. Enter full name including middle name,
and suffix (Sr. Jr. III etc)
2.
2. Enter a complete mailing address and
3.
physical address if different
3. Enter a phone number where you can
be reached.
4.
4. Enter your Social Security Number.
5.
5. Enter your Date of Birth.
WAGE INFORMATION
 Provide the rate of pay as listed on the
worker’s pay stub.
 Include the specific hours the employee is
regularly scheduled each week.
If work hours are not consistent, be
prepared to provide last three months of
pay stubs.
Provide all wages earned from all sources,
including second jobs or home businesses
Include the names and telephone numbers
on any other employment
Revised 04/06

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