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Utah Form Center -

Type & Print Forms - programmed for direct type and print functionality.

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Form

Description

122.pdf Employer's First Report of Injury or Illness
100.pdf Injured Workers' Rights and Responsibilities
123.pdf Physician's Initial Report of Work Injury or Occupational Disease
020.pdf Wage Claim Assignment Form
form043.pdf Attending Physician's Statement
form044.pdf Employee's Intent to Leave State / Change Dr. / Hospital
102.pdf Application to Change Doctors
205.pdf Request for Copies form Claimant's File
302.pdf Medical Records - Copies
134.pdf Application for Lump Sum or Advance Payment
Form089.pdf Employee Notification Denial of Claim
441.pdf Insurance Carrier/ Self Insurers Notice of Further Notification of WC Claim
130.pdf Insurance Company's / Self Insured Final Report of Injury / Statement of Total Loss
141.pdf Initial Statement of Insurance Carrier / Self Insurer with Respect to Payment of Benefits
142.pdf Statement of Insurance Carrier / Self Insurer with Respect to Discontinuance of Benefits
219.pdf Permanent Partial Disability Statement of Compensation
206.pdf Insurer/Employer Initial Reemployment Report for Injured Worker
215.pdf Insurer/Employer Request to Waive/Postpone Reemployment Referral
239.pdf Insurer's Report on Rehabilitation and Reemployment Efforts for Claimants
307.pdf Medical Treatment Provider List - Industrial Accidents
308.pdf Authorization to Disclose, Release and Use Protected Health Information
110.pdf Release to Return to Work
198.pdf Insurer Request for Extension of Time to Obtain 2nd Dental Opinion
221a.pdf Spine Restorative Services Authorization / Denial Form
221b.pdf Upper Extremity Restorative Services Authorization / Denial Form
221c.pdf Lower Extremity Restorative Services Authorization / Denial Form
223.pdf Authorization Request for Medical Procedures
310.pdf Request / Appeal for Additional Medical Information
350.pdf Emergency Medical Service Provider Exposure Report Form
erf.pdf Petition for Reimbursement
Form001.pdf Application for Hearing - Industrial Accident Claim
Form024.pdf Application for Hearing Medical Care Provider
form025.pdf Application for Dependents benefits and/or Burial Benefits - Industrial Accidents Claim
form025inst.pdf Instructions for Filling Out Form 025
form026.pdf Application for Hearing - Occupational Disease Claim
form026inst.pdf Instructions for Filling Out Form 026
form027.pdf Application For Dependents Benefits and/or Burial Benefits - Occupational Disease Claim
form027inst.pdf Instructions for Filling Out Form 027
046.pdf Authorization to Release Labor Commission Records
113a.pdf Summary of Medical Record Industrial Accident
113b.pdf Summary of Medical Record Occupational Exposure
151.pdf Dependent's Benefit Order
152.pdf Appointment of Counsel
402.pdf Application for Hearing For Termination or Reduction of Compensation
sub.pdf Subpoena
poster.pdf POSTER - Workers' Compensation Poster
poster-sp.pdf POSTER - Workers' Compensation Poster - Spanish
uosha.pdf Utah Occupational Safety and Health Poster
uoshasp.pdf Utah Occupational Safety and Health Poster - Spanish
complaint_form.pdf Workers' Compensation Coordination of Benefits Untimely Payment Complaint Form
deathbenguide.pdf Workers' Compensation Guide to Death Benefit Claims