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Employer Request for Risk Management Services
Please utilize this form to request contact from one of the Wyoming Workers' Compensation Risk Managers. If you are experiencing issues with the form, please call 307-777-3353. Thank you!
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* Indicates required question
Company/Legal Business Name
*
Your answer
Workers' Compensation 9-digit Policy Number
Your answer
Are you currently enrolled in any of the Discount Programs? Check any that apply.
*
Drug-Free Workplace Discount
Safety Discount
Deductible Program
Health & Safety Consultation Discount
None at this time
Unsure
Required
I am interested in the following from Risk Management:
*
A full Risk Management Analysis (includes RM visit/video call, trending injury data and presentation)
A discussion on Discount Programs
A discussion on my Experience Modification Rating (EMR)
A discussion on Base Rates/Premium Rates
Loss Run Report
An Ergonomic Evaluation (only offered alongside a Risk Management Analysis)
Other:
Required
If you are interested in a Loss Run Report, please indicate below the time-frame you'd like to see on the report (ie 1/1/15-1/1/18).
Your answer
Please provide your contact information (name, phone and email) so that we can reach out to you.
*
Your answer
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