Application For Hearing / Appeal of Workers' Compensation Claim Denial

An injured worker, or surviving spouse and/or dependents in cases of death, may challenge the employer/insurer’s claim denial by filing an Application for Hearing. There is a different form depending on whether the claim is for an injury by accident or for an occupational disease. There are also separate forms for death claims, depending on whether the death was due to an accident or was the result of occupational disease.

Along with the Application for Hearing, the following forms need to be filed:

  • Medical Treatment Provider List
  • Authorization to Disclose, Release and Use Protected Health Information
  • Summary of Medical Records form or copies of medical records supporting the claim

These forms can be filed in person, by mail, by fax or by e-mail with the Adjudication Division. The employer and the correct insurance carrier, unless the employer is self-insured, must be identified on the Application for Hearing. Click here if you are unable to identify the insurance carrier(s) for the date of injury or period(s) of occupational exposure (disease claim). Incomplete forms will be returned with no action taken.

Once the required completed forms have been filed, they will be mailed to the employer and the designated agent for the employer’s insurance carrier with an Order requiring they file a written Answer within 30 days. Once an Answer has been filed, a hearing will be scheduled no sooner than 120 days from the date the Answer is due. The Division conducts its hearings as formal hearings under the Utah Administrative Procedures Act.

We welcome your questions or comments

Utah Labor Commission
160 East 300 South, 3rd Floor
PO Box 146615
Salt Lake City, Utah 84114-6615
(801) 530-6800
Fax:(801) 530-6333
Monday - Friday 8:00 - 5:00
St George Office
1173 South 250 West, Suite 304
St George, Utah 84770
(435) 634-5580
Fax:(435) 673-2621
Monday - Friday 8:00 - 5:00