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](https://laborcommission.utah.gov/wp-content/uploads/2019/11/Form-044-Fillable.jpg)
Form 043 – Attending Physician’s Statement
![Form 043 - Attending Physician's Statement](https://laborcommission.utah.gov/wp-content/uploads/2019/11/Form-043-Fillable.jpg)
Elevator Inspection Request
![Elevator Inspection Request Form](https://laborcommission.utah.gov/wp-content/uploads/2019/11/Inspection-Request-Form.jpg)
Special Design Plan Cover Sheet
![State Special Cover Sheet](https://laborcommission.utah.gov/wp-content/uploads/2019/11/State-Special-Cover-Sheet.jpg)
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](https://laborcommission.utah.gov/wp-content/uploads/2019/11/Form-441-Revised-2-2019.jpg)
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](https://laborcommission.utah.gov/wp-content/uploads/2019/11/Form-142-Revised-2-2019.jpg)
Form 142 – Statement of Insurance Carrier or Self Insurer With Respect to Discontinuance of Benefits
Form 141 – Initial Statement of Insurance Carrier or Self Insurer With Respect to Payment of Benefits
![](https://laborcommission.utah.gov/wp-content/uploads/Form-141.jpg)
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](https://laborcommission.utah.gov/wp-content/uploads/2019/11/Form-130-Revised-2-2019.jpg)
Form 122 E – Employers First Report Of Injury or Illness
![Form 122 E - Employers First Report Of Injury or Illness](https://laborcommission.utah.gov/wp-content/uploads/2019/11/Form-122-E-Revised-2-2019.jpg)
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](https://laborcommission.utah.gov/wp-content/uploads/2019/11/Form-122-C-Revised-2-2019.jpg)