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Utah Form Center


Welcome to the most extensive library of workers' compensation forms available anywhere. Almost 3,000 forms are available for your immediate download and use. Our forms, all of which have been custom programmed by WorkersCompensation.com for Type & Save functionality, are available for individual purchase below.

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(001) Application for Hearing - 2/08
(024) Medical Care Provider Application for Hearing - 2/08
(025) Application For Dependents benefits and/or Burial Benefits - Industrial Accidents Claim - 2/08
(026) Application For Hearing - Occupational Disease Claim / 2/08
(027) Application For Dependents Benefits and/or Burial Benefits - Occupational Disease Claim - 2/08
(043) Attending Physician's Statement - 7/97
(044) Employee's Intent to Leave State / Change Dr. / Hospital - 3/00
(046) Authorization to Release Labor Commission Records - 6/03
(089) Employee Notification Denial of Claim - N/D
(102) Application to Change Doctors - 3/00
(110) Release to Return to Work - 3/00
(113) Summary of Medical Records - 2/00
(122) Employer's First Report of Injury or Illness - 1/02
(123) Physician’s Initial Report Of Work Injury Or Occupational Disease - 4/05
(130) Insurance Company's / Self Insured Final Report of Injury / Statement of Total Loss - 8/08
(134) Application for Lump Sum or Advance Payment - 2/02
(141) Initial Statement of Insurance Carrier / Self Insurer with Respect to Payment of Benefits - N/D
(142) Statement of Insurance Carrier / Self Insurer with Respect to Discontinuance of Benefits - 8/01
(151) Dependent's Benefit Order - N/D
(152) Appointment of Counsel - N/D
(198) Insurer Request for Extension of Time to Obtain 2nd Dental Opinion - 6/05
(205) Request for Copies form Claimant's File - N/D
(206) Insured Worker State Report - 11/04
(219) Compensation Agreement - 6/07
(221) Restorative Services Authorization / Denial Form - N/D
(223) Authorization Request for Medical Procedures - N/D
(239draft) Insurer’s Report on Rehabilitation and Reemployment Efforts for Claimants - 6/09
(302) Medical Records - Copies - 7/97
(307) Medical Treatment Provider List - Industrial Accidents - 12/08
(308) Authorization to Disclose, Release and Use Protected Health Information - 12/06
(308a) Authorization to Disclose Health Information - Adjudication - 12/06
(309) Medical Treatment Provider List - 12/06
(309A) Medical Treatment Provider List - Adjudication - 12/06
(310) Request / Appeal for Additional Medical Information - 8/05
(350) Emergency Medical Service Provider Exposure Report Form - 9/05
(401) Request for Claims Resolution Conference - 5/01
(402) Application For Hearing For Termination Or Reduction Of Compensation - 7/1/08
(441) Insurance Carrier/ Self Insurers Notice of Further Notification of WC Claim - 11/99
(sub) Subpoena - 7/05
(poster) Workers' Compensation Poster - English - N/D
(poster-sp) Workers' Compensation Poster - Spanish - N/D