University of Wyoming
Risk Management and Insurance

Other States Work Comp

  In order for employees who Live and Work out-of-state to be covered under Workers Compensation, the following form must be completed and submitted prior to the first day of employment. If you have questions contact the Office of Risk Management, 307-766-5767

First name of person filling out this form:

Last name:

Your UW email address:

Department name:

First name of employee:

Last name:

SSN:

First day of employment:

Last day of employment if other than June 30th:

Wages Information

Gross Annual Salary:

Hourly Wage:

$

Employment Status (Select one)

Job Title

Address

City

State

Zip

Work being performed