Forms and Publications Search

Application for Hearing - Industrial Accident Claim
Instructions for Completing Application for Hearing - Industrial Accident Claim

Application for Hearing Medical Care Provider

Application for Hearing - Dependent's Benefits and/or Burial Benefits - Industrial Accidents Claim
Instructions for Completing Application for Hearing - Dependents' Benefits and/or Burial Benefits - Industrial Accident Claim

Application for Hearing - Occupational Disease Claim
Instructions for Completing Application for Hearing - Occupational Disease Claim

Application for Hearing - Dependent's Benefits and/or Burial Benefits - Occupational Disease Claim
Instructions for Completing Application for Hearing - Dependents' Benefits and/or Burial Benefits - Occupational Disease Claim

Attending Physician's Statement
If you are leaving the state of Utah and want to continue receiving medical treatment outside of the state, you will need to file both form 043 and form 044 together and send them to the Labor Commission.

Employee's Notification of Intent to Leave Locality or State, and to Change Doctor or Hospital
If you are leaving the state of Utah and want to continue receiving medical treatment outside of the state, you will need to file both form 043 and form 044 together and send them to the Labor Commission.

Authorization to Release Labor Commission Records

Employee Notification of Denial or Partial Denial of Claim
Basic Insurance Carrier claim form

Application to Change Doctors
If you want to use your 1 time change of doctor, you will need to file this form with the insurance carrier.

Application for Self Insurance

Release to Return to Work
Medical Providers

Summary of Medical Record

Summary of Medical Record - Industrial Accident

Summary of Medical Record - Occupational Exposure

Employers First Report Of Injury or Illness
This form is to be filed by employer to the insurance carrier and the Labor Commission within 7 days of being notified of injury or illness.

Physician's Initial Report of Work Injury or Occupational Disease
This form is to be filed with the Labor Commission within 7 days of a medical provider treating an injured patient for a work related injury.

Insurance Company's and Self Insurer's Final Report of Injury and Statement of Total Losses
Basic Insurance Carrier claim form

Application For Lump Sum or Advance Payment
If you want to get your Permanent Partial Agreement Payment in a Lump Sum, you will need to fill out this form and send it to the Labor Commission for approval.
Basic Insurance Carrier claim form

Initial Statement of Insurance Carrier or Self Insurer With Respect to Payment of Benefits
Basic Insurance Carrier claim form

Statement of Insurance Carrier or Self Insurer With Respect to Discontinuance of Benefits
Basic Insurance Carrier claim form

Dependent's Benefit Information

Appointment of Counsel

Insurer Request for Extension of Time to Obtain 2nd Dental Opinion
Medical Providers

Authorization to Release Industrial Accident Division Records
If you wish to receive copies from the Labor Commission regarding your claim(s), you will need to file this form, have it notorized, then send it to the Labor Commission.

Insurer/Employer Initial Reemployment Report Of Injured Worker
Rehabilitation/Reemployment Form

Application as Certified Reemployment Provider

Self-Insurance Aggregate Surety Bond

Insurer/Employer Request to Waive/Postpone Reemployment Referral
Rehabilitation/Reemployment Form

Agreement of Assumption and Guaranty of Workers' Compensation

Permanent Partial Disability Compensation Agreement
Basic Insurance Carrier claim form

Spine Injury Restorative Services Authorization/Denial
Upper Extremity Restorative Services Authorization/Denial
Lower Extremity Restorative Services Authorization/Denial
Medical Providers -- This form should be submitted to the insurance carrier for approval AND a copy sent to the Labor Commission.

Authorization Request for Medical Procedures/Carrier Response
Medical Providers

Renewal Application for Self Insurance

Insurer/Employer Quarterly Report on Reemployment Efforts for Claimants
Rehabilitation/Reemployment Form

Medical Records - Copies
If you need copies from a Medical Provider for an industrial accident, and the medical provider wants to charge you, you can fill in this form and bring it to the Labor Commission to be signed, so that you can receive a free copy from the medical provider.

Utah Bankruptcy and Insolvency Endorsement

Medical Treatment Provider List

Medical Treatment Provider List
Medical Release Form

Authorization to Disclose, Release and Use Protected Health Information

Authorization to Disclose, Release and Use Protected Health Information (HIPAA Compliant)
Medical Release Form

Medical Treatment Provider List

Medical Treatment Provider List

Request/Appeal for Additional Medical Information
Medical Providers

Emergency Medical Service Provider Exposure Report Form

Request for Claims Resolutiom Conference

Application for Hearing for Termination or Reduction of Compensation
Related publication:Employee's Guide to Hearings for Expedited Workers' Compensation Termination or Reduction of Benefits

Persons With Knowledge List
Related publication:Employee's Guide to Hearings for Expedited Workers' Compensation Termination or Reduction of Benefits

Notice of Filing Application for Hearing for Termination or Reduction of Compensation

Insurance Carriers/Self Insurer's Notice of Further Investigation of a Workers' Compensation Claim
Basic Insurance Carrier claim form

Application for Hearing Failure of Diligent Pursuit

Application for Hearing Noncooperation

Abstract of Award

Commutation Agreement

Compromise Agreement

Continued Dependent's Benefits Declaration

Notice of Designated Agent

Subpoena

Americans With Disabilities Act (ADA) Questionaire
Cuestionario "ADA" (Acto de Americanos con Discapacidades)

Application for Authorization to Employ a Minor

Employer's Response - Wage Claim Investigation

Employment Discrimination Intake Questionaire
Formulario General de Entrada – Discriminacion en el Empleo

Fair Housing Questionnaire
Solicitud de Información Inicial Discriminación en la Vivienda

Wage Claim Assignment Form
Forma de Asignación de Reclamo de Sueldo

Wage Claim Form - Late Payment of Wages
Forma de Reclamo de Multa por Pago Tardío de Sueldo

Miner Certification Test Application
Online application

Variance Request Form
For all Boiler, Elevator and Mine safety code variance requests

IAIABC Electronic Partner Profile

IAIABC Electronic Partnering Agreement

IAIABC Electronic Partnering Insurer/Claim Administrator ID List

IAIABC Electronic Transmission Profile Receiver's Specifications

Petition for Reimbursement From the Employers' Reinsurance Fund

GRAMA Document Request Form

OSHA Consultation Request Form

Notice of Alleged Workplace Safety and/or Health Violation
Aviso Presuntamente de Violación de Seguridad y Salud en el Tabajo

Petition for Modification of Abatement Date (PMA)

Whistleblower Protection

Attorney's Information Sheet - Settlement Agreements

Employee's Guide to Appeal of a Utah Antidiscrimination and Labor Determination and Order
(Request for Evidentiary Hearing)

Employee's Guide to Appealing a Workers' Compensation Claim Denial

Employee's Guide to Hearings for Expedited Workers' Compensation Termination or Reduction of Benefits
Related forms: Form 402 | Form 403

Information for Injured Workers Regarding Settlement Agreements

Instructions for Litigating Antidiscrimination Claims

Letter - Re: Duty Judge Parowan

Letter to Workers' Compensation Attorneys 7/22/2008

Notice of Designated Agent

Rule R602-1. General Provisions.

Rule R602-4. Procedures for Termination of Temporary Total Disability Compensation

Wage Claim Hearings

Workers' Compensation Benefits Present Value Table

Workers'Compensation FAQ

Employment Discrimination - What You Need to Know
Discriminacion en el Empleo

Fact Sheet on Employer Retaliation

Fair Housing Complaint Process
¿Qué puedo esperar cuando presento una queja ante la UALD?

Fair Housing Flyer
Equidad en la Vivienda es su Derecho!

Fair Housing - Your Rights and Responsibilities

Filing a Charge of Employment Discrimination
Como Hacer una Demanda de Discriminacion en el Empleo

Hazardous Occupations That Youth Under 18 Cannot Perform

How to File a Wage Claim
Instrucciones de Como Completar la Forma de Reclamo de Sueldos

Instructions On How To File Late Wage Payment Penalty
Instrucciones de cómo Completar la Forma de la Multa por el Pago Tardío de Sueldo

Sample Nondiscrimination Policy PDF | DOC

State Wage Law Packet

The Resolutions Conference
La Conferencia de Resolucion

Wage Claim Filing Process

Boiler & Pressure Vessel Compliance Manual

Creating the Utah Mine Safety Commission

Division of Boiler, Elevator & Coal Mine Safety - Utah Code

Elevator/Escalator Compliance Manual

Fire Boss Study Guide

Proposed Coal Mine Safety Rules

Surface Electrician Study Guide

Surface Foreman Study Guide

Underground Electrician Study Guide

Underground Fire Boss Study Guide

Underground Mine Foreman Study Guide

Utah Mine Safety Commission Final Report

2008 Annual Report

2009 Annual Report

2010 Annual Report

2011 Annual Report

2011 Worker Classification Annual Report to The Governor

Who We Are - Utah Labor Commission
La Comisión Laboral de Utah
Who We Are - Utah Labor Commission (Arabic)

Workplace Rights Brochure
¡Usted Tiene Derechos En Su Lugar De Trabajo!

2012 Quick Reference Grid
Quick Reference Guide to Workers' Compensation Benefits Effective July 1, 2012

2012 Medical Fee Guidelines

2013 Medical Fee Standards

Bulletin-1-2012 Electronic Data Interchange (EDI) Reporting Requirements and Penalties

Bulletin-6-2011 Liability for Injured Workers’ Medical Expenses Under the “Preferred Provider” Provisions of the Utah Workers’ Compensation Act.

Bulletin-5-2011 Proof of Coverage Reporting Requirements and Penalties

Bulletin-4-2011 Electronic Data Interchange (EDI)

Bulletin-3-2011 Electronic Physicians First Report of Injury (Form 123)

Bulletin-2-2011 Electronic Data Interchange (EDI)

Bulletin-1-2011 Correspondence

Bulletin-8-2010 Proof of Coverage Reporting Requirements and Penalties

Bulletin-1-2010 Electro-Physiologic Testing

Bulletin-10-2009 Reporting Requirements for Insurers and Employers Under the Amended Utah Injured Worker Reemployment Act

Claims EDI Implementation Guide Version 2.1

Death and Burial Benefits

Employee's Guide to Workers' Compensation
Guía Sobre el Seguro de Compensación para los Trabajadores

Employer's Guide to Workers' CompensationEmployers

Injury Description Table Update - Incorporates the Expanded IAIABC Part of Body Coding for Reporting Permanent Impairment Body Part Code

R3 Quick Code Reference List

Unemployment Insurance Poster
Seguro de Desempleo Aviso a los Trabadores

Utah Labor Commission’s Supplemental 2006 Impairment Rating Guides®

Workers' Compcheck Flyer
Utah está en línea con el sistema POC ­ Prueba de Cobertura

Workers Compensation Insurance Organizations Injury Description Codes Cause Of Injury

Workers Compensation Insurance Organizations Injury Description Codes Nature of Injury

Workers Compensation Insurance Organizations Injury Description Codes Part of Body

Workers' Compensation Poster
Compensacion al Trabajador

Utah Adopted the New Crane Safety Standard in Construction

You Have a Right to a Safe and Healthful Workplace. (poster)
Usted Tiene el Derecho a un Lugar de Trabajo Suguro y Saludable (poster)

The 2009 Youth Worker Summer Safety Campaign

The Youth Workers Guide to WorkplaceSafety

A Parent's Guide to Youth Workers

You Have a Right to a Safe and Healthful Workplace.

Industrial Machine Guarding and Control of Hazardous Energy (LOTO)

2009 Material Handling Inspection Emphasis Initiative

Your Rights as a Whistleblower

Utah OSHA Public Sector Consultation