Official Form 142 STATEMENT OF SUSPENSION OF BENEFITS 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, of Suspension of Benefits of 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 Date of Filing: Effective Date: REASON FOR SUSPENSION: Full Suspension Partial Suspension S1 - Returned to Work or Medically Determined/Qualified to Return to Work Return/Release Date: S2- Medical Non-Compliance S3- Administrative Non-Compliance S6- Claimant222s Whereabouts Unknown S7- Benefits Exhausted SJ - Pending Appeal or Judicial Review P1 - Returned to Work or Medically Determined/Qualified to Return to Work Return/Release Date: P2- Medical Non-Compliance P3- Administrative Non-Compliance P7- Benefits Exhausted PJ- Pending Appeal or Judicial Review Reason Narrative : INSTRUCTIONS FOR INSURANCE CARRIER OR SELF - INSURED EMPLOYER: This form is to be completed by the insurance carrier or self-insured employer according to the time frames listed below. A copy must be sent to the physician, if the physician is involved in any way with suspension of Temporary Total Disability compensation. Mandatory Reporting Requirements: Suspension Reasons P1 and S1: Carrier must mail Form 142 to the injured worker within five (5) days of benefits being suspended. All Other Suspension Reasons: Carrier must mail Form 142 to the injured worker five (5) days before benefits are suspended. The benefits must continue to be paid until five (5) days following this notice being mailed to the injured worker. Labor Commission Filing: On claims with a date of injury of July 1, 2019 and forward the suspension must be filed with the Labor Commission using EDI. Claims prior to this date may be filed using EDI or on paper Form 142 and mailed, if preferred. American LegalNet, Inc. www.FormsWorkFlow.com