Official Form 130 FINAL REPORT OF INJURY AND STATEMENT OF TOTAL LOSSES Revised 2/2019 160 East 300 South 3rd Floor P.O. Box 146610 Salt Lake City, Utah 84114-6610 Office: (801)-530-6800 Fax: (801)-530-6804 Toll Free: (800)-530-5090 www.laborcommission.utah.gov TO BE COMPLETED BY I NSURANCE CARRIER OR SELF - INSURED EMPLOYER NOTICE TO INJURED WORKER: This form is to notify you, the injured worker, that your industrial accident or occupational disease claim will be closed. A report of the total losses related to your claim is listed below. If you have questions please contact the adjuster assigned to your claim as listed below. If further assistance is required you may then contact the Labor Commission, Division of Industrial Accidents. INJURED WORKER INFOR MATION: Name: P hone: A ddress: City : State : Zip : SSN : Claim Number: Date of Injury: Employer: Phone : Employer Address : City : State : Zip : Insurance Carrier : Claim Administrator: Adjuster: Phone: Jurisdiction Claim Number (JCN): Adjuster Address: City : State : Zip : PAYMENTS ISSUED: Benefit Type Number of Weeks Amount Paid Per Week Total Paid Temporary Total Disability: $ $ Temporary Partial Disability: $ $ Permanent Partial Disability: $ $ Permanent Total Disability : $ $ Fatality Benefits: $ $ Medical : $ Other: $ Total: $ Date Injured Worker Returned to Work: Light Duty Time Period: Date Injured Worker Returned to Full Duty: Date of Filing: INST RUCTIONS FOR INSURANCE CARRIER OR SELF - INSURED EMPLOYER: This form is to be completed by the insurance carrier or self-insured employer on the same day the claim is closed. This report is required on all claim types, regardless of payment made, with the exception of Notification of an Incident Only as defined by Utah222s first aid rule. This report must include all losses, including: medical only, compensation and survivor benefits. Mandatory Reporting Requirements: Injured Worker: Carrier must mail Form 130 to the injured worker on the same day the claim is closed. Labor Commission Filing: On claims with a date of injury of July 1, 2019 and forward the Final Report of Injury and Statement of Losses must be filed with the Labor Commission using EDI (MTC FN). Claims prior to this date may be filed using EDI or on paper Form 130 and mailed to the Labor Commission , if preferred . American LegalNet, Inc. www.FormsWorkFlow.com