Application For Hearing
Application For Hearing Form. This is a Utah form and can be use in Workers Compensation.
Tags: Application For Hearing, 001, Utah Workers Compensation,
Form 001 2/08 State of Utah - Labor Commission Division of Adjudication 160 East 300 South, 3rd Floor, P.O. Box 146615 Salt Lake City, Utah 84114-6615 (801) 530-6800 laborcommission.utah.gov Note: PLEASE TYPE OR PRINT IN BLACK INK ________________________________________________ Petitioner (Injured Worker) ________________________________________________ Other name(s) used by petitioner (Injured Worker) Vs. ________________________________________________ Respondent (Employer) APPLICATION FOR HEARING Industrial Accident Claim (NOTE: Include all supporting documentation when this form is filed with the Labor Commission or the Application for Hearing may be returned.) I request to have a Claims Resolution Conference scheduled to resolve the issues checked below. ________________________________________________ Respondent’s mailing address ________________________________________________ City, State and Zip Code YES NO ________________________________________________ Respondent’s phone number ________________________________________________ Respondent’s worker’s compensation insurance carrier PETITIONER ALLEGES AND REQUESTS RESOLUTION CONCERNING THE FOLLOWING UNDER TITLE 34A: 1. I sustained an injury by accident arising out of and in the course of my employment with the above named employer on the following date: Month _____ Date _____ Year _______. 2. The accident occurred at the following location: ___________________________________________ __________________________________________________________________________________ 3. The accident occurred as follows: _______________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 4. The injuries I sustained from the accident are: _____________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 5. Petitioner’s birth date: _____________________ 6. At the time of the accident at issue my wage was $_______ per ________, and I was working _______ hours per week. I was _____ was not _____ married and had ______ dependent children. American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR HEARING 7. I claim: (Please mark an “X” next to any issues you want resolved by hearing and attach relevant supporting documentation for each issue marked.) A. Medical Expenses: B. Recommended Medical Care: C. Temporary Total Disability Compensation: (specify the providers and amounts of unpaid medical expenses) __________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ (specify services or treatment) ___________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Time off work from ________to_________; from _______ to _________; from _________to:_________. D. Temporary Partial Disability Compensation: Reduced wages from _______ to_________; from _______ to_______; from _________to:_________. E. Permanent Partial Disability Compensation: F Permanent Total Disability Compensation: G. Travel Expenses: H. Unpaid Interest. I. Other: (specify) ____________________________________________________________________ (specify impairment rating(s) for each injury) ___________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ permanent inability to work. (Important - you must complete the Permanent Total Disability Fact Sheet for permanent total disability compensation claims.) (If you claim reimbursement for travel expenses you must attach a separate sheet with the name of the medical provider, the date(s) of service, and the mileage to the provider for each date.) Petitioner verifies that the above information is true and correct to the best of petitioner’s information and belief. ____________________________________________ Printed Name of Attorney for Petitioner State Bar # ____________________________________________ Signature of Attorney for Petitioner ____________________________________________ Mailing Address for Attorney for Petitioner ____________________________________________ City/State/Zip Code (___)_______________________________________ Telephone Number ____________________________________________ Signature of Petitioner Date ____________________________________________ Mailing Address of Petitioner ____________________________________________ City/State/Zip Code (______)____________________________________ Petitioner’s Telephone Number ____________________________________________ Petitioner’s Social Security Number (___)_______________________________________ FAX E Mail Address American LegalNet, Inc. www.FormsWorkflow.com DOCUMENTS THAT MUST BE FILED WITH APPLICATION FOR HEARING IMPORTANT: Failure to include completed and signed forms with all requested supporting documentation will result in the Application for Hearing being returned for completion. If the returned Application for Hearing is not completed and refiled with the requested supporting documents within sixty (60) days, the Application for Hearing will be dismissed. 1. Form 309A, “Medical Treatment Provider List.” (If you need additional space to list all medical providers you may attach an additional sheet.) 2. Form 308A “Authorization to Disclose Release, Use Protected Health Information.” (HIPAA Compliant.) 3. Form 113, “Summary of Medical Records.” (Petitioner may submit other medical records that provide medical support for the claims of petitioner.) 4. Form 152, “Appointment of Counsel.” (Only required if petitioner is represented by an attorney.) 5. Permanent Total Disability Fact Sheet. (Only required if the claim is for permanent total disability compensation.) If you know the name and address of the adjuster or third party administrator that you have dealt with concerning your claim please include that information: ___________________________________________________ Name of adjuster or third party administrator ___________________________________________________ Mailing address for adjuster or third party administrator ___________________________________________________ City/State/Zip Code American LegalNet, Inc. www.FormsWorkflow.com PERMANENT TOTAL DISABILITY FACT SHEET You must complete this form if you are applying for permanent total disability compensation. 1. Date disability began: __________________________________ 2. Last grade completed in school: __________________________ 3. Diplomas/degrees/licenses/or specialized training completed by petitioner: ____________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 4. Please state whether petitioner can speak and/or read and write in English: ____________________ ________________________________________________________________________________ 5. Attach copies of written physical restrictions provided petitioner by your doctor that prevent or hinder your return to employment. 6. Please identify any jobs petitioner has worked or applied for since the industrial injury at issue in the present case: _____________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 7. Petitioner’s Employment History: (Attach additional sheets if necessary.) Employer Dates of Employment Job Description American LegalNet, Inc. www.FormsWorkflow.com