Print Form FORM 239 - Insurer/Employer Quarterly Report on Reemployment Efforts INSTRUCTIONS: Section 34A-8a-203 of the Utah Injured Worker Reemployment Act requires insurance carriers and employers to submit this quarterly report on their reemployment efforts in behalf of injured workers. This Form 239 � Insurer/Employer Quarterly Report on Reemployment Efforts must be submitted to the Division of Industrial Accidents no later than 45 days after the end of each calendar quarter. Section 34A-8a-203 authorizes the Division to impose a penalty of up to $500 against an insurer or employer for late filing of this quarterly report. The Labor Commission rules and forms related to the Utah Injured Worker Reemployment Act can be found on the Division of Industrial Accidents' website at http://laborcommission.utah.gov/IndustrialAccidents/index.html PLEASE PRINT OR TYPE 1) _____ (Please use MM/DD/YYYY for all dates) Total number of injured workers for whom a reporting entity is required during the previous quarter to file Form 206 � Insurer/Employer Initial Reemployment Report for Injured Worker under Section 34A-8a-301; Total number of disabled injured workers for whom the reporting entity made a referral in accordance with Section 34A-8a-302; 2) _____ 3) _____ Total number of disabled injured workers for whom the reporting entity did not make a referral in accordance with Section 34A-8a-302 because: (i) the injured worker was not medically stable during the quarter; (ii) the injured worker's physical capacity had not been determined during the quarter; or (iii) liability for the injured worker's claim was under review during the quarter; 4) _____ Total number of disabled injured workers reported in Subsection (2)(a) for whom a referral or reemployment plan described in Section 34A-8a-302 was not necessary because: (i) the injured worker returned to work in the same job, a new job, or a modified job: (A) with the same employer; or (B) a new employer; (ii) the injured worker became self-employed; (iii) the injured worker returned to work as a result of vocational rehabilitation support services, as defined by rule by the commission made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act; or (iv) the injured worker's disability was too severe to return to work. Insurer or Employer's Name: _____________________________________________________________ Contact Name: ___________________________________ Job Title: ___________________________ Telephone: (______)___________ Email:__________________________________________________ Mailing Address: ______________________________________________________________________ City: ____________________________________________ State: _______ Zip Code: _________ Date Form 239 submitted: _____ /_____ / _______ for Year: ______ ; 1st, 2nd, 3rd, (MM/DD/YYYY) 4th Quarter (please check one). Form 239 Adopted October 14, 2009 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