Downloads
Adjudication Division
Antidiscrimination and Labor Division
Division of Boiler and Elevator Safety
Industrial Accidents Division
Utah Occupational Safety and Health Division
Workplace Safety
Who we are
Commissioner Decisions
Appeals Board Decisions
Annual Report 2009
On-The-Job Quarterly Newsletter
Forms
Applications For Hearing:
001 Industrial Accident Claim
026 Occupational Disease Claim
024 Medical Care Provider
Supporting Documents:
307 Medical Treatment Provider List
308 Authorization to Release Medical Records
113 Summary of Medical Records (or you may submit actual medical records supporting your claim)
152 Appointment of Counsel (If necessary)
Subpoena
Subpoena
Applications for Hearing on Dependant's Benefits and/or Burial Beneftis
025 Industrial Accident Claim
027 Occupational Disease Claim
Expedited Hearings
402 Application for Hearing - Termination or Reduction of Compensation
502 Application for Hearing Failure of Diligent Pursuit
602 Application for Hearing Noncooperation
403 Persons with Knowledge List
404 Notice of Filing "Application for Hearing for Termination or Reduction of Benefits"
Agreements and Information Documents
Attorney's Information Sheet - Settlement Agreements
Information for Injured Workers Regarding Settlement Agreements
Compromise Agreement
Commutation Agreement
Letter from Commission Regarding Agreements(7/22/2008)
Form 134 Application for Lump Sum or Advance Payment
Publications
410.5 Hearings Fact Sheet
Employee's Guide to a Worker's Compensation Hearing (booklet format)
Wage Claims
Wage Claim Form
Wage Claim Form Spanish
Employment Discrimination
Employment Discrimination Intake Form
Employment Discrimination Intake Form
Spanish
Instructions on Filing an Employment Discrimination Complaint (English)
Como Hacer Una Demanda De Discriminacion En El Empleo (Spanish)
New Employment Publication
ADA Intake Form
Housing Discrimination
Housing Discrimination Intake Form
Housing Discrimination Intake Form Spanish
Fair Housing Flyer
Fair Housing Pamphlet
Sample Nondiscrimination Policy
Boiler/Pressure Vessel Compliance Manual
Elevator Compliance Manual
Division Codes
Variance Request
Miner Certification Test Application
Underground Mine Foreman Study Guide
Surface Mine Foreman Study Guide
Underground Electrician Study Guide
Surface Electrician Study Guide
Fire Boss Study Guide
Forms
Forms to start a claim
122 Employer's First Report of Injury or Illness
123 Physicians First Report of Injury or Illness
Employee Forms
043 Attending Physician's Statement
044 Employee's Intent to Leave State/Change Dr./Hospital
102 Application to Change Doctors
205 Request for Copies from Industrial Accident Division
302 Medical Records - Copies
Carrier Forms
089 Employee Notification Denial of Claim
130 Insurance Company's/Self Insured Final Report of Injury/Statement of Total Loss
141 Initial Statement of Insurance Carrier/Self Insurer with Respect to Payment of Benefits
142 Statement of Insurance Carrier/Self Insurer with Respect to Discontinuance of Benefits
206 Insured Workers Status Report
215 Insurer/Employer Request to Waive/Postpone Reemployment Referral
219 Compensation Agreement
239 Insurer's Report on Rehabilitation and Reemployment Efforts for Claimants
441 Insurance Carrier/Self Insurers Notice of Further Notification of WC Claim
Provider Forms
110 Release to Return to Work
198 Insurer Request for Extension of Time to Obtain 2nd Dental Opinion
221 Restorative Services Authorization/Denial Form
223 Authorization Request for Medical Procedures
310 Request/Appeal for Additional Medical Information
Miscellaneous Forms
350 EMS Form 350
ERF Petition for Reimbursement
151 Dependent's Benefit Order
Posters
Post Workers' Compensation Poster - English
Post-S Workers' Compensation Poster - Spanish
Statistics
2008-2009 UEF Actuarial Report
2008-2009 ERF Actuarial Report
2006 Age of Injured Employee
2006 Injuries by Body Part Injured
2006 Number of Injuries by County
Occupational Fatality Data
Publications
Carrier Publications
Quick Reference Guide 2009 and Grid 2009
Providers Publications
Medical Fee Guidelines 2008 (In effect until December 1, 2009)
2007 WC Handbook for Physicians
2006 Impairment Guides
Workers Compensation Publications
Employee's Guide to Workers' Compensation
Employee's Guide to Workers' Compensation (Spanish)
Employer's Guide to Workers' Compensation
Workers Compensation Guide to Death Benefit Claims
Bulletins
Please go here to view bulletins
Self-Insurance Information
Self Insurance Renewal Application Word Format
Guarantee by Parent Company
Proposed surety bond Claims Administration
Bankruptcy and Insolvency Endorsement
Self Insurance Application
Complaint Form
Employer's First Report of Injury
OSHA Form 300 and 300A (Log and Summary)
Injury, Illness and Fatality Data
Consultation Request Form
Files and Government Records Access Requests (GRAMA)
Utah Occupational Safety and Health Poster-English
Utah Occupational Safety and Health Poster-Spanish
Utah Occupational Safety and Health Discrimination Poster
Grant Application
Project Summary
Scope of Work and Project Description
Safety Award Application
Statement of Work Progress Report