Industrial Accidents Division Forms and Office Locations – Government Agency in Utah

1 - 20 of 25 forms

Form Title	Topics
Form 043 – Attending Physician’s Statement
Form 044 – Employee’s Notification of Intent to Leave Locality or State, and to Change Doctor or Hospital
Form 089 – Employee Notification of Denial or Partial Denial of Claim
Form-100-Spanish-Revised-1-2019
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-Revised-7-2024-Fillable
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
Form 221a – Spine Injury Restorative Services Authorization/Denial
Form 221b – Upper Extremity Restorative Services Authorization/Denial
Form 221c – Lower Extremity Restorative Services Authorization/Denial
Form 223 – Authorization Request for Medical Procedures/Carrier Response
Form 302 – Medical Records – Copies

Industrial Accidents Division