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 bondis   given onlyfor the coverage bylaw pertainingto the work,
                      jobor   contractabovedescribed,andagreesintheeventoftakingotherjobsorcontractsinthe                    Stateof   Wyoming to
              immediately advise   writingin the office   theof Department   Workforceof Services, Workers’ Compensation, 5221 
               Yellowstone Rd,Ch  eyenne,Wyoming,82002,ofsuchfact,thelocationandamountthereof;itbeingunderstood              by 
                    the principalheretothatshouldthecombinedjobsor       contractsbeinexcessoftheamount           coveredbythisbond,    
                  then additional bonds must be   filedin   compliance with provisionsof   the Workers'Compensation Act and the Non- 
     Resident Employer'sBondLaw,asamended.      
 
                  NOW, THEREFORE, the conditionof   this obligationis   such thatif   the principal shall promptlypayand 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 
                   employeesall   wagespayablebytheprincipalinthe       Stateof   Wyoming in connectionwiththeabovedescribedwork,  
                       attheendof twenty four (24) monthsafter thedateuponwhichthisinstrument was receivedbytheDepartment of   
                Workforce Services,thelatterdatetobedeterminedbyDepartmentofWorkforceServices,thenthisobligationshall            
 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