Form 134 8/10 STATE OF UTAH - LABOR COMMISSION Adjudication Division P. O. Box 146615 Salt Lake City, UT 84114-6615 (801) 530-6800 Fax (801)530-6333 casefiling@utah.gov * Name of Employee (printed) Date of Injury Name of Employer (printed) Workers' Compensation Insurance Company of Employer * * * * * * * APPLICATION FOR LUMP SUM OR ADVANCE PAYMENT UNACCRUED AMOUNTS WILL BE SUBJECT TO A DISCOUNT WHICH WILL REDUCE THE AMOUNT PAYABLE BY THE CARRIER Lump Sum payments are permitted under Section 34A-2-421, U.C.A., which states, "An administrative law judge, under special circumstances and when the same is deemed advisable, may commute periodic benefits to one or more lump-sum payments." [Emphasis added] To determine whether special circumstances exist, the administrative law judge requires answers to the following questions: 1. Are you employed at the present time? YES _________ NO ______ If so, name of Employer: ___________________________________________________________________ Monthly earnings: __________________________________________________________________________ 2. Are you presently engaged in a vocational rehabilitation program? Name of Rehabilitation Counselor: YES_____ NO 3. Is your spouse employed? YES______ NO ______ If so, name of employer: ____________________________________________________ Number of children under 18 living at home: _______ List monthly obligations such as rent, food utilities, car payments. Use other side, if necessary. 4. 5. 6. 7. 8. 9. Do you or your spouse receive monthly benefits from any other source? YES Amount of cash in savings account(s) or bonds: How much money are you requesting to be advanced? What are the reasons for making this request? ____________ $ $ NO The Undersigned hereby certifies that the information listed above is true and correct and the money requested will be used only for the purposes indicated. Signature of Applicant City/State/Zip Date Approved: _________________ By Street Address Telephone Administrative Law Judge Request denied for the following reasons: Date Denied _______________________ By Administrative Law Judge American LegalNet, Inc. www.FormsWorkFlow.com R612. Labor Commission, Industrial Accidents. R612-1. Workers' Compensation Rules - Procedures. R612-1-4. Discount. Eight percent shall be used for any discounting or present value calculations. Lump sums ordered by the Commission or for any attorney fees paid in a single up-front amount, or of any other sum being paid earlier than normally paid under a weekly benefit method shall be subject to the 8% discounting. For purposes of calculating the 8% discount, please reference Publications R612-1-4 Present Value Table: http://www.laborcommission.utah.gov/Downloads.html#Adjudication American LegalNet, Inc. www.FormsWorkFlow.com