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Application For Hearing For Termination Or Reduction Of Compensation 402 - Utah

Application For Hearing For Termination Or Reduction Of Compensation Form. This is a Utah form and can be used in Workers Compensation .
 Fillable pdf Last Modified 2/4/2014
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Form 402 3/1/12 StateofUtahLaborCommission AdjudicationDivision 160East300South,3rdFloor,P.O.Box146615 SaltLakeCity,Utah841146615 (801)5306800 casefiling@utah.gov Note:PLEASETYPEORPRINTINBLACKINK Employer(Petitioner) Employer'sMailingAddress City,StateandZipCode Employer'sEMailAddress Petitioner'sWorkers'CompInsuranceCarrier InsuranceCarrier'sMailingAddress City,StateandZipCode InsuranceCarrier'sEMailAddress vs. Respondent(Employee) Respondent'sMailingAddress City,StateandZipCode Respondent'sPhoneNumber APPLICATIONFORHEARING FORTERMINATIONORREDUCTIONOF COMPENSATION (NOTE:Includeallsupportingdocumentationwhen thisformisfiledwiththeLaborCommissionorthe ApplicationforHearingmaybereturned) SupportingDocumentationRequiredforthis Application: ProofofService NoticeofRequestforTerminationorReductionof Compensation PersonswithKnowledgeList PETITIONERALLEGESANDREQUESTSRESOLUTIONCONCERNINGTHEFOLLOWINGUNDERTITLE 34A: 1. 2. 3. Dateofindustrialinjury:Month __________ Date________Year________ . Petitioner requests respondent's compensation be (check one) _______terminated or ______reducedby$_________perweek. Thebasisforthisreduction/terminationis: _____________ (listspecificcitationto┬ž34A2410.5 relieduponforthisrequest).Thepetitionerallegesthefollowinginsupportofthisclaim: American LegalNet, Inc. www.FormsWorkFlow.com Form 402 3/1/12 Petitionerverifiesthattheaboveinformationistrueandcorrecttothebestofpetitioner's informationandbelief. PrintedNameofAttorneyforPetitioner/Respondent SignatureofPetitioner StateBar# SignatureofAttorneyforPetitioner/Respondent Petitioner'sTelephoneNumber Date MailingAddressforAttorneyforPetitioner/Respondent City/State/ZipCode TelephoneNumber FAX EMailAddress American LegalNet, Inc. www.FormsWorkFlow.com
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