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Workers Comp Claims Forms
- Form 122 - Employers First Report of Injury or Illness
- This form is to be filed by employer to the insurance carrier and the Labor Commission within 7 days of being notified of injury or illness.
- Form 123 - Physicians First Report of Injury or Illness
- This form is to be filed with the Labor Commission within 7 days of a medical provider treating an injured patient for a work related injury.
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:
- Form 043 Attending Physician's Statement
- 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:
Basic Claim Forms
- Form 089 Employee Notification of Denial or Partial Denial of a Claim
- Form 441 Insurance Carrier/Self Insurers Notice of Further Notification of Claim
- Form 130 Insurance Company's/Self Insured Final Report of Injury/Statement of Total Loss
- Form 141 Initial Statement of Insurance Carrier/Self Insurer with Respect to Payment of Benefits
- Form 142 Statement of Insurance Carrier/Self insurer with Respect to Discontinuance of Benefits
- Form 219 Permanent Partial Compensation Agreement
- Form 134 Application for Lump Sum
Rehabilitation/Reemployment Forms
- Form 206 Insured Work Status Report
- Form 215 Insurer/Employer Request to Waive/Postpone Reemployment Referral
- Form 239 Insurers Report and Rehabilitation Efforts for Claimants
Medical Release Forms
- Form 110 Release to Return to Work
- Form 198 Insurer Request for Extension of Time to Obtain @nd Dental Opinion
- Form 221a Spine Restorative Services Authorization/Denial Form
- This form should be submitted to the insurance carrier for approval AND a copy sent to the Labor Commission.
- Form 221b Upper Extremity Restorative Services Authorization/Denial Form
- This form should be submitted to the insurance carrier for approval AND a copy sent to the Labor Commission.
- Form 221c Lower Extremity Restorative Services Authorization/Denial Form
- This form should be submitted to the insurance carrier for approval AND a copy sent to the Labor Commission.
- Form 223 Authorization Request for Medical Procedures
- Form 310 Request/Appeal for Additional Medical Information
