Form 130 – Insurance Company’s and Self Insurer’s Final Report of Injury and Statement of Total Losses
Form 122 E – Employers First Report Of Injury or Illness
Form 122 C – Insurance Carrier/Self Insured Employer First Report of Injury or Illness
Form 100 – Injured Workers’ Rights and Responsibilities (Spanish)
Form 100 – Injured Workers’ Rights and Responsibilities
Form 089 – Employee Notification of Denial or Partial Denial of Claim
Form 303 – Utah Bankruptcy and Insolvency Endorsement
Form 223E – Renewal Application for Self Insurance
Form 215E – Agreement of Assumption and Guaranty of Workers’ Compensation
Form 213E – Self-Insurance Aggregate Surety Bond
