Forms

Common Workers’ Comp Forms

Here is a collection of common forms used during your workers’ compensation claim process. Your attorney will be able to help you determine which forms you may need to resolve your claim. Click on the image of the form to be taken to the form.

Form 089 – Employee Notification of Denial or Partial Denial of Claim

Your insurance carrier should send you a copy of this form when they deny your claim.

Form 102 – Application to Change Doctors

This form can be used to make your one-time change of doctor.

Form 113a – Summary of Medical Record – Industrial Accident

This form is for your doctor to prepare in order to bolster the medical aspects of your claim. It allows the doctor to state that the injury you suffered was at work, the treatment necessary to help you return to work, the restrictions necessary for any light duty work, and the extent of any permanent damage.

Form 113b – Summary of Medical Record – Occupational Exposure

This form is for your doctor to prepare in order to bolster the medical aspects of your claim. It allows the doctor to state that the occupational disease or exposure (not an accident injury) you suffered was at work, the treatment necessary to help you return to work, the restrictions necessary for any light duty work, and the extent of any permanent damage.

Form 122 C – Insurance Carrier First Report of Injury or Illness

Your workers’ compensation insurance carrier must file this form with the Utah Labor Commission when they have been notified of your injury. They also must provide you with a copy (or of Form 089 if denying coverage).

Form 122 E – Employer’s First Report of Injury or Illness

This form is filled out by your employer when you have notified them of your injury. A copy should be provided to the insurance carrier and to the injured worker. You will want to provide a copy of the completed form to your Attorney for review.

Form 123 – Physician’s Initial Report of Work Injury or Occupational Disease

This form is filled out by the doctor you see after you have been injured at work. It is important to let the doctor know that you have been injured at work so that the physician can fill out this form. The doctor must provide a copy of this form to your employer, the insurance carrier, and to the injured worker (you). If you have seen a doctor after being hurt at work and they did not give you a copy of this form, please send this one to them and request that they fill it out and file it properly. You will want to provide a copy of the completed form to your attorney for review.

Form 130 – Final Report of Injury and Statement of Total Losses

This form is filled out by the workers’ compensation carrier (insurance company) when your claim is closed. It should be provided to you, the injured worker, upon completion of any payments for medical, disability, and/or survivor benefits.

Form 141 – Statement of Benefits Paid

This form is completed by your workers’ compensation insurance carrier on the first day that any benefits are paid. It shows you how the rate of compensation was calculated. This completed form should be provided to you, the injured worker on the same day that the first payment is issued to you. It is critical that you provide a copy of this form to your Attorney to verify if your benefit payments are calculated correctly.

Form 152 – Appointment of Counsel

Your Attorney will need you to sign this form in order to represent you in your workers’ compensation claim.

Form 205 – Authorization to Release Industrial Accident Division Records

This form is needed in order to get a copy of your records from the Utah Labor Commission.

Form 307 – Medical Treatment Provider List

This form is where you list all the doctors who have treated you for the past 10 years. It allows the insurance company to review your past injuries to determine whether your current work injury is a result of your work accident or if some pre-existing condition is involved in your current symptoms.

Form 308 – HIPAA Release

This form is used to authorize the insurer to gain access to your medical records and comply with HIPAA regulations. You will need to have your signature notarized on this form.

Workplace Safety & Health Complaint Form (UOSH)

More Forms at the Labor Commission Site

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