Adjudication Hearing Forms
Here is a list of the forms, with links to PDF files that can be printed, that are required when filing an Application for Hearing.
Please fill them out completely. Then send them back via fax, regular mail or e-mail to firstname.lastname@example.org.
Application for Workers' Compensation Claim Denial Hearing Forms
Which form do I choose?
Accident or Occupational Disease?
In most cases, an industrial accident is a single event that occurs on a specific date. An occupational disease is a condition that results from occupational exposure over a period of time. Utah law also recognizes claims for a repetitive trauma accident. This is an industrial accident due to repetitive trauma. If your claim involves a repetitive injury or disease, you are strongly advised to seek legal counsel to decide whether it should be claimed as a repetitive trauma accident claim or an occupational disease claim. The legal standards for these claims are different and the choice of claim can affect the amount (if any) you may be able to recover. The Adjudication Division cannot give you legal advice about which type of claim to file.
Multiple Injury Dates: You must file a separate Application for Hearing for each injury date, whether or not it was with the same employer. You must file a separate Application for Hearing for each period of exposure with different employers. You may file all of the Applications at the same time. All of the Applications will be combined into one case.
Applications for Hearing Workers’ Compensation Claim Denial:
- 001 Industrial Accident Claim
- 026 Occupational Disease Claim
Applications for Hearing on Dependant's Benefits and/or Burial Benefits Denial:
- 025 Industrial Accident Claim
- 027 Occupational Disease Claim
Application for Hearing Medical Care Provider Claim Denial (For Medical Care Providers Only):
Compensation Termination/Reduction Hearings:
- 402 Application for Hearing - Termination or Reduction of Compensation
- 403 Persons with Knowledge List
- 404 Notice of Filing "Application for Hearing for Termination or Reduction of Benefits"
PTD Reemployment Dispute Hearings:
- 403 Persons with Knowledge List
- 502 Application for Hearing Failure of Diligent Pursuit
- 602 Application for Hearing Noncooperation
Agreements and Information Documents:
- Attorney's Information Sheet - Settlement Agreements
- Information for Injured Workers Regarding Settlement Agreements
- Compromise Agreement
- Commutation Agreement
- Commissioner Letter Regarding Agreements (7/22/2008)
- Form 134 Application for Lump Sum or Advance Payment
- Employee’s Guide to Appeal of a Utah Antidiscrimination and Labor Division Determination Publications
- Employee’s Guide for Expedited Workers’ Compensation Termination or Reduction of Benefits
- Employee's Guide to a Workers’ Compensation Hearing
- Workers' Compensation Discount Calculator
Appeal of a Utah Occupational Safety and Health Penalty Forms:There is no Required Request for Evidentiary Hearing form.
Appeal of a Utah Antidiscrimination and Labor Division Determination and Order (Request for Evidentiary Hearing) Forms:There is no Required Request for Evidentiary Hearing form.
- Instructions for Litigating Antidiscrimination Claims
- Employee’s Guide to Appeal of a Utah Antidiscrimination and Labor Division Determination
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