STATE OF WYOMING DEPARTMENT OF WORKFORCE SERVICES DIVISION OF WORKERS' COMPENSATION CLAIM FOR NON-MEDICAL SERVICES 307-777-7441 PLEASE PRINT OR TYPE IN BLACK INK Injured Worker Information CLAIM # SSN # DATE OF INJURY NAME ADDRESS CITY STATE ZIP Payee Information FEDERAL TAX ID # OR SOCIAL SECURITY # Required for payment DATE OF BIRTH NAME ADDRESS CITY PHONE # ( ) STATE ZIP DESCRIPTION: Please provide a detailed description of services rendered. Also attach any related documents which may clarify, explain, DATES OF SERVICE or support the charges being billed. FROM TO AMOUNT SUBMITTED I hereby certify under penalty of perjury, that all items billed above were rendered solely on account of the original compensable injury and are true, accurate and complete to the best of my knowledge. TOTAL Payee Signature (required) Date services or CLAIM MAY BE DENIED INSTRUCTIONS FOR FILING: Submit billing no later than the 30th of each month for prior month's MAIL ORIGINAL TO: Division of Workers' Compensation PO Box 20070 Cheyenne, WY 82003-7001 WSCD-6N (Rev 12/11) American LegalNet, Inc. www.FormsWorkFlow.com