Form 141 – Initial Statement of Insurance Carrier or Self Insurer With Respect to Payment of Benefits

Form 142 – Statement of Insurance Carrier or Self Insurer With Respect to Discontinuance of Benefits

Form 213E – Self-Insurance Aggregate Surety Bond

Form 215E – Agreement of Assumption and Guaranty of Workers’ Compensation

Form 219 – Permanent Partial Disability Statement of Compensation

Form 221a – Spine Injury Restorative Services Authorization/Denial

Form 221b – Upper Extremity Restorative Services Authorization/Denial

Form 221c – Lower Extremity Restorative Services Authorization/Denial

Form 223 – Authorization Request for Medical Procedures/Carrier Response

Form 302 – Medical Records – Copies

Form 303 – Utah Bankruptcy and Insolvency Endorsement

Form 350 – Emergency Medical Service Provider Exposure Report Form