Free Utah Workers Compensation Forms

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65 Forms found in Utah — Workers Compensation — Page 1 of 2
Title Last Updated
Subpoena October 14, 2015
Statement Of Insurance Carrier Or Self Insurer With Respect To Discontinuance Of Benefits October 14, 2015
Request For Claims Resolution Conference October 14, 2015
Insurance Companys And Self Insurers Final Report Of Injury And Statement Of Total Losses October 14, 2015
Insurance Carriers Self Insurers Notice Of Further Investigation Of A Workers Compensation Claim October 14, 2015
Authorization Request For Medical Procedures Carrier Response October 14, 2015
Application To Change Doctors October 14, 2015
Authorization To Disclose Release And Use Protected Health Information (HIPAA Compliant) August 4, 2015
Application For Hearing August 4, 2015
Application For Hearing (Occupational Disease Claim) August 4, 2015
Medical Treatment Provider List August 4, 2015
Corporate Officer Exclusion From Workers Compensation Or Employers Liability Coverage August 4, 2015
Application For Hearing Medical Care Provider August 4, 2015
Medical Records Copies August 3, 2015
Employees Notification Of Intent To Leave Locality Or State And To Change Doctor Or Hospital August 3, 2015
Initial Statement Of Insurance Carrier Or Self Insurer With Respect To Payment Of Benefits August 3, 2015
Release To Return To Work July 31, 2015
Restorative Services Authorization Denial (Spine) July 29, 2015
Physicians Initial Report Of Work Injury Or Occupational Disease July 29, 2015
Permanent Partial Disability Agreement July 29, 2015
Employers First Report Of Injury Or Illness July 29, 2015
Employee Notification Of Denial Or Partial Denial Of Claim July 29, 2015
Medical Treatment Provider List September 5, 2014
Authorization To Release Industrial Accident Division Records July 23, 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
Insurer Request For Extension Of Time To Obtain 2nd Dental Opinion August 21, 2013
Emergency Medical Service Provider Exposure Report Form August 21, 2013
Application For Lump Sum Or Advance Payment August 21, 2013
Restorative Services Authorization Denial November 11, 2008
Application For Dependents Benefits And Or Burial Benefits (Occupational Disease Claim) June 18, 2008
Application For Dependents Benefits And Or Burial Benefits June 18, 2008
Medical Care Provider Application For Hearing June 18, 2008
Appointment Of Counsel June 17, 2008
Dependents Benefit Information June 17, 2008
Summary Of Medical Record June 17, 2008
Authorization To Disclose Release And Use Protected Health Information (Adjudication) June 17, 2008