Workforce Services, Department of

Workers' Compensation Division

Chapter 4: Injury Report Procedure

Effective Date: 04/02/2004 to 08/10/2022

Rule Type: Superceded Rules & Regulations

Reference Number: 053.0021.4.04022004

Rules, Regulations and Fee Schedules of the Wyoming Workers' Compensation Division

CHAPTER 4 - INJURY REPORT PROCEDURE

Section 1. Worker Report of the Injury. The report of the injury is not a claim for benefits. W.S. § 27-14-503(a). The injured worker is required by the statute to report the occurrence and general nature of the injury to the employer as soon as practical within 72 hours after the injury becomes apparent, and to file a signed injury report on the required form with the Division within ten days after the injury becomes apparent. Otherwise, there is a statutory presumption that the claim shall be denied. However, this presumption may be rebutted if the worker can establish by clear and convincing evidence that the delay does not prejudice the employer or Division in investigating the injury and in monitoring medical treatment.

Section 2. Contents of the Worker's Report. The report shall be on a form provided by the Division, available from the Division or employer, and shall contain the following information:

1. (a) The worker's full name, mailing address, telephone number and Social Security Number;
2. (b) The worker's birth date, sex, marital status and number of dependents;
3. (c) The employer's full name, address and telephone number;
4. (d) The worker's date of hire and job title;
5. (e) A statement of whether the worker is a regular worker, volunteer, inmate, a governmentally subsidized work experience program participant, or has an interest in the business as owner, partner, or corporate officer;
6. (f) The worker's current monthly earnings;
7. (g) The date, time and location of the accident or injury;
8. (h) A statement of how the injury occurred, including what the worker was doing at the time and what objects or substances caused the injury;
9. (j) A statement identifying the parts of the worker's body affected by the injury;
10. (k) The name(s) of any witness(es) to the events causing the injury;
11. (l) The names and addresses of all health care providers who have treated or provided medical services to the worker for the injury being reported;
12. (m) If the report is prepared by a person other than the worker, the full name, address and telephone number of the person preparing the report, and that person's relationship to the worker;

Rules, Regulations and Fee Schedules of the Wyoming Workers' Compensation Division

(n) Such additional information as the Division deems appropriate; and

(o) The report form shall be signed and dated by the worker, or his personal representative if the worker is incapacitated.

Section 3. Employer Report of the Injury. The employer must file a report of injury within ten days after the date on which the employer is notified of the injury. Failure by an employer to report may result in a fine or jail. W.S. § 27-14-506(c). The report must be filed with the Division; it shall be on the required form, dated, signed by the employer or employer's authorized representative and shall contain the following information:

(a) The worker's date of hire and job title;

(b) A statement of whether the worker is a regular employee, volunteer, inmate, governmentally subsidized work experience program participant, or has an interest in the business as owner, partner or corporate officer;

(c) The worker's current monthly earnings;

(d) The opinion of the employer as to whether the worker suffered a work-related injury that is compensable under the Act; and

(e) If the employer's opinion is that the injury is not compensable under the Act, the employer shall specify its reason for that opinion. Those matters will be addressed by the Division as part of the determination process.

Section 4. Injury Report Forms. Injury report forms are available, without charge, from the Division or its district offices. W.S. § 27-14-502(a) and (c). The limitation of time for filing does not apply if the worker is mentally incompetent or a minor and has no guardian. W.S. § 27-14-505. The report form shall contain a statement in boldface type that the report is not a claim for benefits.

Section 5. Notification of Injury. Any affected party may give notice, by electronic means to the Division, of an occurrence of injury to a worker in covered employment. Upon receipt of notice of injury, the Division will mail the appropriate forms to the injured worker and the employer for completion and signatures.

(a) If notification was electronically submitted within the deadline prescribed in W.S. § 27-14-502(a) and the Division receives the signed report within ten days of its mailing by the Division, the report shall be deemed to have been timely filed. In such a case, the Division's allotted time to respond will begin when it receives the signed report.

(b) If the Division receives the signed report more than ten days after its mailing by the Division, the report shall be deemed filed on the date the signed report is received by the Division.

Rules, Regulations and Fee Schedules of the Wyoming Workers' Compensation Division

(c) The Division will not approve any award nor pay any claim prior to its receipt of a signed waiver from the injured employee, on a form provided by the Division, authorizing the Division to release benefit, employment or medical information to those parties designated recipients in W.S. § 27-14-805(d).

(d) Nothing in this section shall relieve any party of the duty to submit documents bearing original signatures, when required by the Act or these Rules.