| Title |
Last Updated |
| Authorization To Disclose Release And Use Protected Health Information (HIPAA Compliant) |
June 21, 2019 |
| Insurance Companys And Self Insurers Final Report Of Injury And Statement Of Total Losses |
June 20, 2019 |
| Insurance Carriers Self Insurers Notice Of Further Investigation Of A Workers Compensation Claim |
June 20, 2019 |
| Employee Notification Of Denial Or Partial Denial Of Claim |
June 20, 2019 |
| Employers First Report Of Injury Or Illness |
June 18, 2019 |
| Statement Of Insurance Carrier Or Self Insurer With Respect To Discontinuance Of Benefits |
June 14, 2019 |
| Initial Statement Of Insurance Carrier Self Insurer Payment Of Benefits |
June 14, 2019 |
| Application For Hearing |
September 13, 2018 |
| Application For Hearing (Occupational Disease Claim) |
September 13, 2018 |
| Trucking Questionnaire |
September 13, 2018 |
| Application For Dependents Benefits And Or Burial Benefits |
June 15, 2018 |
| Subpoena |
November 30, 2016 |
| Appointment Of Counsel |
November 30, 2016 |
| Application For Dependents Benefits And Or Burial Benefits (Occupational Disease Claim) |
November 30, 2016 |
| Authorization To Release Industrial Accident Division Records |
November 30, 2016 |
| Release To Return To Work |
July 26, 2016 |
| Restorative Services Authorization Denial (Spine) |
June 13, 2016 |
| Authorization Request For Medical Procedures Carrier Response |
March 30, 2016 |
| Application To Change Doctors |
March 30, 2016 |
| Request For Claims Resolution Conference |
October 14, 2015 |
| Physicians Initial Report Of Work Injury Or Occupational Disease |
August 26, 2015 |
| Insurer Request For Extension Of Time To Obtain 2nd Dental Opinion |
August 26, 2015 |
| Medical Records Copies |
August 26, 2015 |
| Attending Physicians Statement |
August 26, 2015 |
| Corporate Officer Exclusion From Workers Compensation Or Employers Liability Coverage |
August 10, 2015 |
| Application For Hearing Medical Care Provider |
August 10, 2015 |
| Medical Treatment Provider List |
August 10, 2015 |
| Employees Notification Of Intent To Leave Locality Or State And To Change Doctor Or Hospital |
August 3, 2015 |
| Permanent Partial Disability Agreement |
July 29, 2015 |
| Emergency Medical Service Provider Exposure Report Form |
April 13, 2015 |
| Application For Lump Sum Or Advance Payment |
April 13, 2015 |
| Medical Treatment Provider List |
September 5, 2014 |
| Workers Compensation Coverage Waiver |
February 4, 2014 |
| HBA Participation Agreement |
February 4, 2014 |
| Petition For Reimbursement From The Employers Reinsurance Fund |
February 4, 2014 |
| Persons With Knowledge List |
February 4, 2014 |
| URCA Participation Agreement |
February 4, 2014 |
| UMA Participation Agreement |
February 4, 2014 |
| UTA Participation Agreement |
February 4, 2014 |
| Notice Of Filing Application For Hearing For Termination Or Reduction Of Compensation |
February 4, 2014 |
| Authorization To Disclose Release And Use Protected Health Information (Adjudication) |
February 4, 2014 |
| Application For Hearing For Termination Or Reduction Of Compensation |
February 4, 2014 |
| Application For Hearing Failure Of Diligent Pursuit |
February 4, 2014 |
| AGC Participation Agreement |
February 4, 2014 |
| Restorative Services Authorization Denial (Upper Extremity) |
August 21, 2013 |
| Restorative Services Authorization Denial (Lower Extremity) |
August 21, 2013 |
| Medical Treatment Provider List (Adjudication) |
August 21, 2013 |
| Application For Utah Workers Compensation And Utah Liability Insurance |
July 11, 2012 |
| General Business Supplemental Questionnaire |
July 11, 2012 |
| Request Or Appeal For Additional Medical Information |
July 11, 2012 |
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