Out of State Employer Questionnaire - Wyoming …

1 WYO-790 (1/2018) Wyoming D epartment of Workfor ce Services Out of State Employer Questionnair e Email: (attach completed form(s) to email message) Fax: (307) 235-3278 Mail: Unemployment Insurance Tax Division Attn: Registration Unit Box 2760 Casper, WY 82602 Company Name (Legal Business Name): Address: City S tate Zip: Contact Person Name: Phone: Email: A physical address in Wyoming is REQUIRED DO NOT USE your Registered Agent s address or a PO Box. Your application cannot be processed without a valid physical Wyoming address. 1. Does y our company have a Wyoming r esident perfor ming services f or your company i n Wyoming ?

2 Type o f l ocation: Home Office Address: 2. Has your company been awarded the contract for a proj ect in Wyoming ? Yes No If Yes: What is t he pr oject name and location? Start Date: How lon g will this project last? How long will your company be w or king at t hi s location? Is this a public works job? Yes No Will y our compa ny hi re Wyoming residents t o wor k on the pr oject? Yes No Date of f irst payroll: Does y our company e xpect t o pay salaries over $10,000 pe r mont h for wor k performed i n Wyoming ?

3 Yes No 3. Is y our company t he G eneral Contractor on this p roject? Yes No (Please prov ide a list of all subcontractor s. The list mus t i nclude name, addr ess and contact na me and phone numbe r f or all subcontractor s) **You ar e responsible t o obtai n a current Certificate o f Good Standing for Unemploy ment Insurance for each subcontrac tor you h ire on a ll Wyoming jobs** 4. Prov ide information on all projects w or ked in Wyoming withi n the last 12 months . (attach additional sheets if needed) Project Name and Location Project Start Date Project End Date How long was your company on the job?

4 Amount of Monthl y Payrol l in Wyoming 5. Is y our company currently submitti ng bids for fut ur e pr ojects i n Wyoming ? Yes No Please pr ov ide all known information about the futur e project. (attach additional sheets if needed) Project Name and Location Project Start Date Project End Date How long will y our company be on the job? Amount of Monthl y Payrol l in Wyoming 6. Who currently p rov ides Workers Compensation Cov erage for your company? Carrier Name o r State Policy or Account Number Does y our Policy cover ALL e mpl oy ees who are w or king i n Wyoming ?

5 Yes No If No, and you a re in a n industry required to have worke rs compens ation cov erage under Wyoming l aw, you will be r equired to obtain Wyoming Workers Compensation for all empl oyees wor ki ng in Wyoming w ho are not c ov ered under your existing policy ** **You must provide proof of WC cov erage provided by your insurance company**