Get WY WCD-9 2016-2021
ITS Please return the completed form to the address or fax shown above. An incomplete application may result in a denial of benefits. Name (Print or Type) Social Security Number Date of Birth Date of Injury Address City, State, Zip Phone Number Email Address Per §27-14-404(d)(iii), you are ineligible for temporary total disability benefits if you are receiving unemployment benefits. Any attempt to obtain temporary total disability benefits while receiving unemployment compensation may r.
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