Official Form 441 NOTICE OF FURTHER INVESTIGATION OF WOKERS222 COMPENSATION CLAIM 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 not ify you, the injured worker, of further investigation by the insurance carrier or self-insured employer prior to accepting or denying your industrial accident or occupational disease claim. 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: Address: 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 REASON FOR INVESTIGATION : Reason Narrative : INSTRUCTIONS 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 put under investigation. Rule 612-200-1(C(1)(a) If, with reasonable diligence, an insurance carrier, self-insured employer, or uninsured employer cannot complete its investigation within 21 days after initial notice, it may complete and submit Division Form 441, "Notice of Further Investigation of a Workers' Compensation Claim" notify the Division and claimant that the matter remains under investigation. The insurance carrier, self-insured employer, or uninsured employer is then allowed 24 days in addition to the initial 21-day period to complete its investigation and accept or deny liability of the claim. Mandatory Reporting Requirements: Injured Worker: Carrier must mail Form 441 to the injured worker on the same date the claim is put under investigation Labor Commission Filing: Investigations for claims with a date of injury of December 31, 2012 and forward must be filed with the Labor Commission using EDI (MTC UI). Claims prior to this date may be filed using EDI or on paper form 441 and mailed, if preferred. American LegalNet, Inc. www.FormsWorkFlow.com