Anti-Discrimination Forms and Office Locations – Government Agency in Utah

41 - 55 of 55 forms

Form Title	Topics
Form 100 – Injured Workers’ Rights and Responsibilities
Form 100 – Injured Workers’ Rights and Responsibilities (Spanish)
Form 102 – Application to Change Doctors
Form 109 – Application for Self Insurance
Form 122 C – Insurance Carrier/Self Insured Employer First Report of Injury or Illness
Form 122 E – Employers First Report Of Injury or Illness
Form 123 – Physician’s Initial Report of Work Injury or Occupational Disease
Form 130 – Insurance Company’s and Self Insurer’s Final Report of Injury and Statement of Total Losses
Form 134 Application for Lump Sum or Advance Payment
Form 141 – Initial Statement of Insurance Carrier or Self Insurer With Respect to Payment of Benefits
Form 142 – Statement of Insurance Carrier or Self Insurer With Respect to Discontinuance of Benefits
Form 205 – Authorization to Release Industrial Accident Division Records
Form 213E – Self-Insurance Aggregate Surety Bond
Form 215E – Agreement of Assumption and Guaranty of Workers’ Compensation
Form 219 – Permanent Partial Disability Statement of Compensation

Anti-Discrimination