Wyoming Workers' Compensation Final Determination Hearing Request
WYOMING WORKERS' COMPENSATION FINAL DETERMINATION HEARING REQUEST
File promptly. Wyo. Stat. § 27-14-601(k)(iv) gives an interested party 15 days after the Division mails its Final Determination to file a written hearing request. Follow the response instructions and due date in the actual letter, and keep proof of filing. This request addresses the identified Final Determination; it does not replace an injury report or benefit application.
Date: [__/__/____]
To: Wyoming Department of Workforce Services
Workers' Compensation Claims
P.O. Box 20207
Cheyenne, WY 82003
From: [REQUESTING PARTY FULL NAME]
Mailing address: [________________________________]
Telephone: [PHONE] Email: [EMAIL]
Employee: [FULL NAME] Employer: [NAME]
Claim number: [NUMBER] Date of injury: [__/__/____]
Final Determination date: [__/__/____] Date mailed, if shown: [__/__/____]
Re: Written objection and request for hearing on Final Determination
I object to the Division's Final Determination identified above and request a hearing before a hearing examiner under Wyo. Stat. § 27-14-601(k)(iv).
Part of the determination disputed: [IDENTIFY THE INJURY, BILL, BENEFIT, PERIOD, AMOUNT, OR OTHER DECISION BEING CHALLENGED.]
Reason for objection: [EXPLAIN THE MATERIAL FACTS AND WHY THE IDENTIFIED DECISION IS WRONG. IDENTIFY RELEVANT RECORDS.]
Result requested: [STATE THE FINDING, BENEFIT, PAYMENT, OR CORRECTION SOUGHT.]
Documents enclosed, if any: [LIST THE FINAL DETERMINATION AND ANY SUPPORTING RECORDS SUBMITTED WITH THIS REQUEST.]
Please acknowledge receipt and send notices about the hearing to the address above.
Requesting party or authorized representative signature: [SIGNATURE] Date: [__/__/____]
Printed name and capacity, if signing for a party: [NAME / CAPACITY]
Filing record: [DELIVERY METHOD / DATE / TRACKING OR CONFIRMATION NUMBER]
Official sources
About this template
- Last updated
- October 27, 2026
- Citations checked
- October 27, 2026
- Jurisdiction
- Wyoming
- Category
- Employment & HR
Legal authority
- Wyo. Stat. § 27-14-601(k)(iv) (written request and 15-day filing period)
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on October 27, 2026.
Wyo. Stat. § 27-14-601(k)(iv) (checked October 27, 2026): "Any interested party may request a hearing before a hearing examiner on the final determination of the division by filing a written request for hearing"
Wyo. Stat. § 27-14-601(k)(iv), deadline (checked October 27, 2026): "within fifteen (15) days after the date the notice of the final determination was mailed by the division."
Wyoming Judicial Branch, A Guide to Workers' Compensation for Wyoming Claimants, p. 11 (checked October 27, 2026): "If you disagree with any Final Determination letter, you must send a written objection and request for hearing to Workers’ Compensation."
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