Out Of State Employer Questionnaire Form Page 2

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4. Is your company currently working on other projects in Wyoming?
Yes
No
If Yes, provide information on each of those projects.
(attach additional sheets if needed)
How long
Amount of
Project
Project
Project Name and Location
will your
Monthly
Start
Expected
company be
Payroll in
Date
End Date
on the job?
Wyoming
5. In the last 12 months, how many projects has your company worked in Wyoming?
Provide information on each project below.
(attach additional sheets if needed)
How long
Amount of
Project
Project
was your
Monthly
Start
Project Name and Location
End Date
company on
Payroll in
Date
the job?
Wyoming
6. Is your company currently submitting bids for future projects in Wyoming?
Yes
No
If your company is the successful bidder, how long will each of these projects last?
(attach additional sheets if needed)
How long
Approximate
Anticipated
would your
duration of
Monthly Payroll
Project Name and Location
company be
the Project
in Wyoming
on the job?
7.
Who currently provides Workers’ Compensation Coverage for your company?
Carrier Name or State:
Policy or Account Number:
Does your Policy cover Wyoming Residents who are working in Wyoming?
Yes
No
If No, and you are in an industry required to have workers’ compensation coverage
under Wyoming law, you will be required to obtain Wyoming Workers’ Compensation
for all employees working in Wyoming who are not covered under your existing
policy
provided by your insurance company.
Attach proof of WC coverage

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