Transcription of WY Report of Injury v1 - Wyoming Workforce
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WY Report of Injury v1 - Wyoming Workforce
Department of Workforce Services Division of Workers' Compensation Report of InjuryIMPORTANT: PLEASE COMPLETE THE BACKSIDE OF THIS FORMINJRPT Revised 11/11 EMPLOYER INFORMATIONP lease use BLACK ink. Do not cross zeros or sevensClaim Number:BUSINESS NAMEWORK COMP EMPLOYER #ADDRESSCITYSTATEZIPPHONETAX ID TYPE (FEIN OR SSN)TAX ID NUMBERNATURE OF BUSINESS (MANUFACTURING, ETC.)EMPLOYEE INFORMATIONLAST NAMEFIRST NAMEMIMAILING ADDRESSCITYSTATEZIPPHYSICAL ADDRESS (IF DIFFERENT FROM MAILING ADDRESSCITYSTATEZIPPHONE (WITH AREA CODE)EMAIL ADDRESSDATE OF BIRTHDATE OF HIRESTATE OF HIRESOCIAL SECURITY NUMBERUS CITIZEN?YESNOIF NO, PROVIDE INS#SEXFEMALEMALEMARITAL STATUSSINGLEMARRIEDDIVORCEDWIDOWEDINJURY INFORMATIONDATE OF INJURYTIME OF INJURYAMPMTIME EMPLOYEE BEGAN WORKAMPMTIME EMPLOYEE ENDED WORKAMPMDATE EMPLOYER WAS NOTIFIED OF INJURYLAST DAY OF WORK AFTER INJURYDATE OF RETURN TO WORKEMPLOYEES OCCUPATION (JOB TITLE) WHEN INJUREDTYPE OF EMPLOYEEREGULARVOLUNTEERINMATEOTHEREMPLO YEE STATUSOWNERPARTNERCORPORATE OFFICERINDEPENDENT CONTRACTORNAME OF PERSON CONTACTEDCONT)
Department of Workforce Services Division of Workers' Compensation Report of Injury INJRPT IMPORTANT: PLEASE COMPLETE THE BACKSIDE OF THIS FORM Revised 11/11 EMPLOYER INFORMATION Please use BLACK ink. Do not cross zeros or sevens Claim Number: BUSINESS NAME WORK COMP EMPLOYER #
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