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Adjudication – Forms

Here is a list of the forms that are required when filing an Application for Hearing. Please fill them out completely. Then send them back via fax, regular mail or e-mail to

Application for Workers’ Compensation Claim Denial Hearing Forms

Which form do I choose?

Accident or Occupational Disease?
In most cases, an industrial accident is a single event that occurs on a specific date. An occupational disease is a condition that results from occupational exposure over a period of time. Utah law also recognizes claims for a repetitive trauma accident. This is an industrial accident due to repetitive trauma. If your claim involves a repetitive injury or disease, you are strongly advised to seek legal counsel to decide whether it should be claimed as a repetitive trauma accident claim or an occupational disease claim. The legal standards for these claims are different and the choice of claim can affect the amount (if any) you may be able to recover. The Adjudication Division cannot give you legal advice about which type of claim to file.

Multiple Injury Dates: You must file a separate Application for Hearing for each injury date, whether or not it was with the same employer. You must file a separate Application for Hearing for each period of exposure with different employers. You may file all of the Applications at the same time. All of the Applications will be combined into one case.

Applications for Hearing on Dependant's Benefits and/or Burial Benefits Denial:

Application for Hearing Medical Care Provider Claim Denial (For Medical Care Providers Only):

Appointment of Counsel (For Attorney Use Only):


Appeal of a Utah Occupational Safety and Health Penalty Forms:

Appeal of a Utah Antidiscrimination and Labor Division Determination and Order (Request for Evidentiary Hearing) Forms: