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Forms

Industrial – Forms

Start of a Claim

Claims Intake Questionnaire

EDI Claims – Trading Partner application

EDI POC – Trading Partner application

Physician’s Initial Report of Work Injury or Occupational Disease

Form 100 - Injured Workers’ Rights and Responsibilities

Form 100 – Injured Workers’ Rights and Responsibilities

Form 100 - Injured Workers’ Rights and Responsibilities (Spanish)

Form 100 – Injured Workers’ Rights and Responsibilities (Spanish)

Form 122 C - Insurance Carrier/Self Insured Employer First Report of Injury or Illness

Form 122 C – Insurance Carrier/Self Insured Employer First Report of Injury or Illness

Form 122 E - Employers First Report Of Injury or Illness

Form 122 E – Employers First Report Of Injury or Illness

Form 123 - Physician's Initial Report of Work Injury or Occupational Disease

Form 123 – Physician’s Initial Report of Work Injury or Occupational Disease

Employees

Form 043 - Attending Physician's Statement

Form 043 – Attending Physician’s Statement

Form 044 - Employee's Notification of Intent to Leave Locality or State, and to Change Doctor or Hospital

Form 044 – Employee’s Notification of Intent to Leave Locality or State, and to Change Doctor or Hospital

Form 102 - Application to Change Doctors

Form 102 – Application to Change Doctors

Insurance Carriers Basic Claims Forms

Form 089 - Employee Notification of Denial or Partial Denial of Claim

Form 089 – Employee Notification of Denial or Partial Denial of Claim

Form 130 - Insurance Company's and Self Insurer's Final Report of Injury and Statement of Total Losses

Form 130 – Insurance Company’s and Self Insurer’s Final Report of Injury and Statement of Total Losses

Form 134 Application for Lump Sum or Advance Payment

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

Form 219 - Permanent Partial Disability Statement of Compensation

Form 219 – Permanent Partial Disability Statement of Compensation

Form 441 - Insurance Carriers/Self Insurer's Notice of Further Investigation of a Workers' Compensation Claim

Form 441 – Insurance Carriers/Self Insurer’s Notice of Further Investigation of a Workers’ Compensation Claim

Insurance Carriers/Self-Insurance

Petition for Reimbursement From the Employers' Reinsurance Fund

Petition for Reimbursement From the Employers’ Reinsurance Fund

Records Request Form

Form 205 - Authorization to Release Industrial Accident Division Records

Form 205 – Authorization to Release Industrial Accident Division Records

Medical Release Records Form

Form 302 - Medical Records - Copies

Form 302 – Medical Records – Copies

Medical Provider Forms

Form 221a - Spine Injury Restorative Services Authorization/Denial

Form 221a – Spine Injury Restorative Services Authorization/Denial

Form 221b - Upper Extremity Restorative Services Authorization/Denial

Form 221b – Upper Extremity Restorative Services Authorization/Denial

Form 221c - Lower Extremity Restorative Services Authorization/Denial

Form 221c – Lower Extremity Restorative Services Authorization/Denial

Form 223 - Authorization Request for Medical Procedures/Carrier Response

Form 223 – Authorization Request for Medical Procedures/Carrier Response

Form 350 - Emergency Medical Service Provider Exposure Report Form

Form 350 – Emergency Medical Service Provider Exposure Report Form

Self-Insurance Forms

Application for Self Insurance

Renewal Application for Self Insurance

Form 213E - Self-Insurance Aggregate Surety Bond

Form 213E – Self-Insurance Aggregate Surety Bond

Form 215E - Agreement of Assumption and Guaranty of Workers' Compensation

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

Form 303 - Utah Bankruptcy and Insolvency Endorsement

Form 303 – Utah Bankruptcy and Insolvency Endorsement

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