Get the free utah workers' compensation forms

Consequences of Failure to Comply. 1. Pursuant to Subsection 34A-2-407 8 of the Utah Workers Compensation Act the Division may impose a civil assessment of up to 500 for an insurance carrier insured employer or self-insured employer or uninsured employer s failure without good cause to comply with the requirements of this rule. cc Labor Commission Employee Official Form 441 Revised 10/14 State of Utah Labor Commission Division of Industrial Accid...

How to fill out utah workers compensation forms

How to fill out Utah workers compensation form:

1. Obtain the form: The Utah workers compensation form can be obtained from the Utah Labor Commission website or from your employer.
2. Provide personal information: Fill out the form with your personal information, including your name, address, phone number, and social security number.
3. Fill out employer information: Provide details about your employer, including their name, address, and contact information.
4. Describe the injury: Clearly explain the nature of your work-related injury or illness on the form. Include information about how and when the injury occurred.
5. Medical treatment information: Provide details about the medical treatment you have received for your injury. Include the names of healthcare providers, dates of treatment, and any medications prescribed.
6. Employment details: Fill out information related to your employment, such as your job title, wage rate, and the date of hire.
7. Witnesses and statements: If there were any witnesses to your injury, include their contact information on the form. Additionally, you may need to provide a written statement describing how the injury occurred.
8. Submit the form: Once you have completed all the necessary sections, sign and date the form. Submit it to your employer or the Utah Labor Commission as instructed.

Who needs Utah workers compensation form?

1. Employees: Any employee who sustains a work-related injury or illness in Utah may need to fill out the workers compensation form.
2. Employers: Employers are responsible for providing the workers compensation form to their employees and ensuring they have access to it.
3. Utah Labor Commission: The Utah Labor Commission requires certain information from employees who have suffered work-related injuries or illnesses to process workers compensation claims. Therefore, they may also need the completed form.

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What is utah workers compensation form?

Utah workers compensation form is a document that employers are required to fill out to report their workers' compensation insurance coverage and provide information about their employees and workplace.

Who is required to file utah workers compensation form?

All employers in Utah are required to file the workers compensation form, regardless of the number of employees they have.

How to fill out utah workers compensation form?

To fill out the Utah workers compensation form, employers need to provide information about their company, employees, payroll, job classifications, and insurance coverage. The form can be completed online or submitted in paper format.

What is the purpose of utah workers compensation form?

The purpose of the Utah workers compensation form is to ensure that employers have adequate workers' compensation insurance coverage to protect their employees in case of work-related injuries or illnesses. It also helps in tracking workplace safety and compliance with regulations.

What information must be reported on utah workers compensation form?

The Utah workers compensation form requires employers to report information such as their company name, address, federal employer identification number (FEIN), number of employees, job classifications, payroll amounts, and insurance carrier details.