W.C.U.11(07-18)                                                      Bond Number#                           
                                                                        Employer #_________________ 

                    STATE OF WYOMING DEPARTMENT OF  

                      WORKFORCE SERVICES 
 
                    Non-Resident Employers' Surety Bond 
                    GIVEN IN LIEU OF DEPOSIT OF CASH OR OTHER SECURITY UNDER 
                     WYOMING STATUES 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 Company)
 
 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  State of Wyoming 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 State of Wyoming, and is about to engage 
 in the performance of certain business activities, in the State of Wyoming    requiring the use or employment and 
 payment of wages to workers in extra hazardous and/or non-extra hazardous 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 State of Wyoming to 
 immediately advise in writing the office of the Department of Workforce Services, 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  Department  of  Workforce  Services,  Workers’  Compensation,  Occupational Health and Safety(OSHA), 
 Unemployment Insurance, and Labor Standards as and when required by the Department of Workforce Services, 
 State of Wyoming, 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 State of Wyoming 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 Department of 
 Workforce Services, the latter date to be determined by Department of Workforce Services, then this obligation shall 
 be void. 

 Non-Resident Employers’ Surety Bond                                                                                           
 
 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 Workers’ Compensation Division 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 Department of Workforce Services in the name of the State of Wyoming, 
 for  the  use  and  benefit  of  the  Workers' Compensation  Division,  the  Labor Standards  Section, OSHA, and 
 Unemployment Insurance that neither the principal or surety shall raise or interpose the defense in such suit that the 
 State of Wyoming is not the proper oblige 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 Workers' Compensation 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  Workers’  Compensation, 

 whichever is later.  That if the Principal does pay the wages, or any premiums, and penalties due of the Principal 
 working in the State of Wyoming, 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