State of Wyoming Department of Workforce Services THE DIVISION OF WORKERS' COMPENSATION 1510 East Pershing Boulevard Cheyenne, WY 82002

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1 NON-RESIDENT EMPLOYER BOND REQUIREMENTS EFFECTIVE JULY 1, 2018 Non-resident employers are those employers that have not resided in the for one (1) full year prior to beginning operations in this State. Non-resident employers must file the following bond in support of their Workers' Compensation account and to ensure the payment of wages to any and all employees employed in Wyoming. A minimum $8, Non-Resident Employer's Surety Bond must be filed in all cases when expected wages are greater than $4, The amount of the bond may be greater than $8,000.00, depending upon the size of your monthly payroll. The Surety Bond increases by $2, for each $1, (or fraction thereof) in excess of $4, of expected wages. If expected wages exceed $20,000.00, the Surety Bond increases by $1, for each $1, (or fraction thereof) of expected wages. This bond must be kept in place for a period of at least two years and there is no maximum amount for the bond W.S An alternate method of payment for the Surety Bond requirement is a Cash Deposit, which may be in the form of a Cashier's Check or a Letter of Credit from your Financial Institution. There is also an arrangement whereby equity in owned real property in Wyoming may be used for security. * * * * * * * * * * * * * * * * * * * * * * * * * Penalty For Failure to Post Bond: Wyoming Statute states "The willful failure of any nonresident employer in a covered employment to give bond or other security required by this act constitutes a misdemeanor, punishable by a fine of not more than five thousand dollars ($5,000.00), imprisonment for not more than one (1) year, or both." * * * * * * * * * * * * * * * * * * * * * * * * * Pursuant to W.S (e), the director may permit withdrawal of any security if the employer has: 1. Complied with the security requirements and made all necessary payments for two (2) years; 2. Demonstrated the employer has been a resident of the State for two (2) years and intends to remain a resident; 3. Acquired real property as a non-resident with an equity value greater than or equal to the value of the bond or other security required; 4. Complied with all other requirements under the Workers' Compensation Act. No account will be considered in compliance until all requirements with the Workers' Compensation Act have been met. BOND WC1203 Revised 07/18 Page 1 of 5 We Bridge Human and Economic Development for Wyoming's Future. PHONE: FAX:

2 AFFIDAVIT AFFIRMING AMOUNT OF MONTHLY PAYROLL EMPLOYER: EMPLOYER #: Effective July 1, 2018, Wyoming Workers' Compensation modified its requirements for Non-Resident Employer Collateral Bond Requirements. A Surety Bond, Letter of Credit, or an Advance Cash Premium is not required for employers with an average monthly payroll of $4, a month or less. Read the following statements and sign the affidavit below. Submit the signed copy to any of the Division's field offices or send to: WYOMING WORKERS' COMPENSATION 1510 EAST PERSHING BLVD 2 ND FLOOR CHEYENNE WY I, the undersigned, do affirm that the total monthly (or anticipated payroll) for this account is $. If the total monthly payroll exceeds $4,000.00, I do hereby acknowledge that a Surety Bond, Letter of Credit, or an Advance Cash Premium will be furnished to all. Print Name Title Signature Date Penalty For Failure to Post Bond: Wyoming Statute states "The willful failure of any nonresident employer in a covered employment to give bond or other security required by this act constitutes a misdemeanor, punishable by a fine of not more than five thousand dollars ($5,000.00), imprisonment for not more than one (1) year, or both." BOND WC1203 Revised 07/18 Page 2 of 5 We Bridge Human and Economic Development for Wyoming's Future. PHONE: FAX:

3 W.C.U. 11 (07-18) Bond Number: Employer Number: STATE OF WYOMING DEPARTMENT OF WORKFORCE SERVICES Non-Resident Employers' Surety Bond GIVEN IN LIEU OF DEPOSIT OF CASH OR OTHER SECURITY UNDER WYOMING STATUTES TITLE 27 LABOR AND EMPLOYMENT KNOW ALL MEN BY THESE PRESENTS: That we, (Name and Address of Principals) as principals and (Name and Address of Surety) as surety, are held and firmly bound into THE STATE OF WYOMING, in the full and just sum of, ($ ) Dollars, lawful [Minimum legal requirement Eight Thousand Dollars ($8,000.00)] money of the United States of America, to be paid to the for the use and benefit of the Workers' Compensation Fund, Occupational Health and Safety Division (Wyoming Industrial Accident Fund), Unemployment Insurance Fund, and Labor Standards Division, to insure payment of wages or debts in the State of Wyoming. WHEREAS, the undersigned principal is a non-resident employer of the, and is about to engage in the performance of certain business activities, in the requiring the use or employment and payment of wages to workers in extrahazardous and/or non-extrahazardous occupations as defined by the Wyoming Workers' Compensation Act, to-wit: (Describe type of operations and amount of anticipated monthly payroll) And WHEREAS, said principal recognizes this bond is given only for the coverage by law pertaining to the work, job or contract above described, and agrees in the event of taking other jobs or contracts in the to immediately advise in writing the office of the, Workers' Compensation, 1510 East Pershing Blvd, Cheyenne, Wyoming, 82002, of such fact, the location and amount thereof; it being understood by the principal hereto that should the combined jobs or contracts be in excess of the amount covered by this bond, then additional bonds must be filed in compliance with provisions of the Workers' Compensation Act and the Non-Resident Employer's Bond Law, as amended. NOW, THEREFORE, the condition of this obligation is such that if the principal shall promptly pay and reimburse the, Workers' Compensation, Occupational Health and Safety (OSHA), Unemployment Insurance, and Labor Standards as and when required by the,, any and all premiums and penalties due the Division and promptly pays to the principal's employees all wages payable by the principal in the in connection with the above described work, at the end of twenty four (24) months after the date upon which this instrument was received by the, the latter date to be determined by, then this obligation shall be void.

4 Non-Resident Employers' Surety Bond Page 2 AND THEREFORE, if the anticipated work has ceased before the expiration of twenty-four (24) months, or less than fifty percent (50%) of the largest work force is still working in Wyoming, the security deposited by the nonresident employer shall be forfeited and retained by the Division of Workers' Compensation in an amount equal to the reserved amounts for compensable injuries to the nonresident employer's employees. It is agreed by both the principal and surety that in case the principal shall default in the conditions of this obligation, suit on this obligation may be brought by the in the name of the, for the use and benefit of the Workers' Compensation Division, the Labor Standards Division, OSHA, and Unemployment Insurance that neither the principal or surety shall raise or interpose the defense in such suit that the is not the proper obligee to be named in this bond provided the amount which may be recovered in such suit be, by order of the Court having jurisdiction of the suit, paid into Wyoming Industrial Accident Fund or Unemployment Insurance Fund, and applied as a credit to the separate account of the principal or paid to the Administrator of the Labor Standards Section as trustee for unpaid workers. THAT the effective date of commencement of the obligations of the Principal and Surety hereunder is the day of, 20, or the date received by the Department of Workforce Services, whichever is later. That if the Principal does pay the wages, or any premiums, and penalties due of the Principal working in the, according to law, for that period commencing with the effective date and ending two years thereafter, then this bond shall be void, otherwise to remain in full force and effect. Effective date of bond: the day of 20. By: Principal By: Attorney-in-Fact, Surety

5 DETERMINING AMOUNT OF NON-RESIDENT EMPLOYERS' SURETY BOND Monthly payroll from through bond amount $0 $ 4,000 - EXEMPT $ 4,001 $ 5,000 - $ 8,000 $ 5,001 $ 6,000 - $ 10,000 $ 6,001 $ 7,000 - $ 12,000 $ 7,001 $ 8,000 - $ 14,000 $ 8,001 $ 9,000 - $ 16,000 $ 9,001 $ 10,000 - $ 18,000 $ 10,001 $ 11,000 - $ 20,000 $ 11,001 $ 12,000 - $ 22,000 $ 12,001 $ 13,000 - $ 24,000 $ 13,001 $ 14,000 - $ 26,000 $ 14,001 $ 15,000 - $ 28,000 $ 15,001 $ 16,000 - $ 30,000 $ 16,001 $ 17,000 - $ 32,000 $ 17,001 $ 18,000 - $ 34,000 $ 18,001 $ 19,000 - $ 36,000 $ 19,001 $ 20,000 - $ 38,000 $ 20,001 $ 21,000 - $ 39,000 $ 21,001 $ 22,000 - $ 40,000 $ 22,001 $ 23,000 - $ 41,000 $ 23,001 $ 24,000 - $ 42,000 $ 24,001 $ 25,000 - $ 43,000 $ 25,001 $ 26,000 - $ 44,000 $ 26,001 $ 27,000 - $ 45,000 $ 27,001 $ 28,000 - $ 46,000 If monthly expected wages exceed $20,000, the bond amount will continue to increase by $1,000 for each additional $1,000 of monthly payroll (or fraction thereof).

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