Form 001 07/01/18 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 casefiling@utah.gov (for cases north of Nephi) sgcasefiling@utah.gov (for cases south of Nephi) Note: PLEASE TYPE OR PRINT CLEARLY IN INK. Petitioner Other Name(s) Used By Petitioner vs. Respondent (Employer) Respondent222s Mailing Address City, State And Zip Code Respondent222s Worker222s Comp Insurance Carrier* Insurance Carrier222s Mailing Address City, State And Zip Code 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 that a Claims Resolution Conference be scheduled to resolve the issues checked below YES NO *It is the Petitioner222s obligation to provide themailing address and phone number forrespondent222s insurance carrier. If you do nothave this information, you may obtain it on theLabor Commission website or the IndustrialAccidents Division Workers222 Compcheck. You mayalso contact the employer or the IndustrialAccidents Division. PETITIONER STATES AS FOLLOWS: 1a. 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 . 1b. I sustained an injury by repetitive trauma arising out of and in the course of my employment with the above named employer during the period of Month Date Year to Month Date Year. 2.The accident occurred at the following location: American LegalNet, Inc. www.FormsWorkFlow.com Form 001 07/01/18 Describe the accident with a focus on how you were injured: The injuries I sustained from the accident are: My birth date is:At the time of the accident, my wage was $ per, and I was working hoursper week. I was was not married and had dependent children. If youearned wages on some other basis, such as $1/mile or $5/piece, please explain how much youearned each week:THE BENEFITS I AM SEEKING ARE: Please mark an 223X224 next to any issues you want resolved and attach relevant supporting documentation for each issue marked. Do not check benefits which do not apply to your case. For more information about what benefits you may be entitled to, please see our website http://laborcommission.utah.gov/divisions/IndustrialAccidents/Claims.html . You may also find this guide useful: http://laborcommission.utah.gov/media/pdfs/industrialaccidents/pubs/EEGuide.pdf) A. Medical Expenses. Specify the providers and amounts billed to date. You may need to update thisinformation in your pretrial disclosures. B. Recommended Medical Care. Specify services or treatment. You may need to update thisinformation in your pretrial disclosures. C. Temporary Total Disability Compensation. Time off work from to ;from to ; from to: . D. Temporary Partial Disability Compensation. Reduced wages from to ;from to ; from to: . American LegalNet, Inc. www.FormsWorkFlow.com Form 001 07/01/18 E. Permanent Partial Disability Compensation. Specify impairment rating(s) for each injury. You must also attach medical records or a Summary of Medical Records form showing the impairment rating calculated by a physician. F. Permanent Total Disability Compensation. This means that you are permanently unable to work. (Important: You must complete the Permanent Total Disability Fact Sheet for permanent total disability compensation claims.) G. Travel Expenses. (Important: 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.) H. Unpaid Interest. I. Other. Specify: I verify that the above information is true and correct to the best of my information and belief. Name of Petitioner222s Attorney State Bar # Attorney222s Signature Attorney222s Mailing Address City/State/Zip Code () Telephone Number () FAX Attorney222s E-Mail Address Petitioner222s Signature Date Petitioner222s Mailing Address City/State/Zip Code () Petitioner222s Telephone Number Petitioner222s E-Mail Address American LegalNet, Inc. www.FormsWorkFlow.com Form 001 07/01/18 Documents That MUST Be Filed With Your Application For Hearing Form 307 Medical Treatment Provider List You may attach additional pages if necessary. Form 308 Authorization to Disclose Health Information (HIPAA Compliant) Form 113a Summary of Medical Record You may submit other medical records that provide medical support for your claims butyou must highlight the language that shows the relationship between the injury andyour employer. Permanent Total Disability Fact Sheet Only required if the claim is for permanent total disability compensation. Third Party Administrator 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 Email Address City/State/Zip Code IMPORTANT: Failure to include completed and signed forms with all of the necessary supporting documentation will result in the Application for Hearing being returned to you for completion. If the returned Application for Hearing is not completed and refiled with the requested supporting documents within 60 days, the Application for Hearing will be dismissed without prejudice, which means that you can file a new Application for Hearing once you have collected all of the information required. American LegalNet, Inc. www.FormsWorkFlow.com Form 001 07/01/18 Permanent Total Disability Fact Sheet You must complete this form if you are applying for permanent total disability compensation. Date my disability began: .Last grade I completed in school: .Diplomas/degrees/licenses/or specialized training I completed: I can speak and/or read and write in English: Attach copies of written physical restrictions provided by your doctor that prevent your returnto work, or which make it more difficult for you to return to work. Please make sure to highlightthe restrictions.These are the jobs I worked at or have applied for since the industrial injury:My Employment History: (Attach additional sheets if necessary). Employer Dates of Employment Job Description American LegalNet, Inc. www.FormsWorkFlow.com