Workers Comp Claims Forms

To Start a Claim
Employees

If you are leaving the state of Utah and want to continue receiving medical treatment outside of the state, you will need to file the following forms together and send them to the Labor Commission:

  1. Form 043 Attending Physician's Statement
  2. Form 044 Employee's Intent to Leave State/Change Doctor/Hospital

If you want to use your 1 time change of doctor, you will need to file the following form with the insurance carrier:

If you wish to receive copies from the Labor Commission regarding your claim(s), you will need to file the following form, have it notorized, then send it to the Labor Commission:

If you need copies from a Medical Provider for an industrial accident, and the medical provider wants to charge you, you can fill in the following form and bring it to the Labor Commission to be signed, so that you can receive a free copy from the medical provider:

If you want to get your Permanent Partial Agreement Payment in a Lump Sum, you will need to fill out the following form and send it to the Labor Commission for approval:

Medical Providers




 160 E. 300 S., 3rd Floor, Salt Lake City, UT 84111
(801) 530-6800 or (800) 530-5090
laborcom@utah.gov
Hours: Mon-Fri 8am-5pm