Print Form Form 151 DEPENDENT'S BENEFIT INFORMATION PLEASE PRINT OR TYPE Insurance Carrier Claim Number _________________________Name of Decedent _________________________ Date of Industrial Injury or Occupational Disease _________________Date of Death_______________________ Employer Name ___________________________ Industrial Carrier/TPA (circle one) ______________________ JOB(s) ON DATE CLAIM AROSE WAGE PER HOUR HOURS WORKED PER WEEK TOTAL WAGES PER WEEK FOR ALL JOBS = Dependent Information PRESENT ADDRESS NAME RELATIONSHIP BIRTH DATE (Including State/City/Zip) This claim has been (check one): Accepted in full ________ Accepted in part _________ Denied _________ If all or part of the claim has been denied, please attach Form 089 -"Employee Notification of Denial of Claim." ADJUSTER/AUTHORIZED AGENT CONTACT INFORMATION Name_________________________________________Signature______________________________________ Mailing Address ___________________________________________________ City/State/Zip _____________________________________________________ Telephone Number ___________________ FAX Number _______________________________ Official Form 151 Revised 2/09 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com