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 307-777-8901. Thank you!
Company/Business Legal 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. *
Required
I am interested in the following from Risk Management: *
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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