Get Wyoming Employeess Application For Temporary Total Disability Benefits Form

Completing the Wyoming Employees Application For Temporary Total Disability Benefits Form is a crucial step for individuals seeking temporary total disability benefits due to work-related injuries. This guide provides a clear and supportive process for filling out the form effectively online.

Follow the steps to fill out the form accurately online.

1. Press the ‘Get Form’ button to download the Wyoming Employees Application For Temporary Total Disability Benefits Form and open it in your preferred editor.
2. Fill in the ‘Name’ field with your full name, ensuring it is printed clearly.
3. Enter your ‘Claim Number’ in the provided section to link your application to your workers' compensation claim.
4. Provide your complete ‘Address’, including city, state, and ZIP code, to facilitate communication.
5. Input your ‘Date of Birth’ to verify your age and eligibility.
6. Include the ‘Last 4 Digits of Social Security Number’ for identification purposes.
7. Indicate if this is a new address by selecting ‘Yes’ or ‘No’.
8. Specify your ‘Date of Injury’ to establish the timeline of your claim.
9. Provide a contact ‘Phone Number’ where you can be reached.
10. Answer the questions about your current employment status and any part-time or full-time work since the injury, as well as inquiries regarding requests for suitable job duties and unemployment benefits.
11. Indicate whether you are required to make child support payments as mandated by court order.
12. Sign and date the declaration to confirm the information is accurate and authorize the division to access necessary information.
13. For medical certification, have your health care provider complete their section, including their name, certification of your temporary disability, and any required supporting details about your condition.
14. Review all sections for accuracy and completeness before submitting.
15. Save your completed form, and choose to download, print, or share it as needed.

Complete the Wyoming Employees Application For Temporary Total Disability Benefits Form online to ensure your benefits are processed promptly.