Utah > Workers Compensation
Application For Hearing 001 - Utah
| Application For Hearing Form. This is a Utah form and can be used in Workers Compensation . |
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Form 001 3/1/12 State of Utah - Labor Commission Division of Adjudication 160 East 300 South, 3rd Floor, P.O. Box 146615 Salt Lake City, Utah 84114-6615 (801) 530-6800 casefiling@utah.gov Note: PLEASE TYPE OR PRINT IN BLACK INK ___________________________________________________________ Petitioner ___________________________________________________________ Other name(s) used by petitioner vs. ___________________________________________________________ Respondent (employer) ___________________________________________________________ Respondent's mailing address ___________________________________________________________ City, State and Zip Code ___________________________________________________________ Respondent's phone number ___________________________________________________________ Respondent's workers' comp Insurance Carrier* ___________________________________________________________ Insurance Carrier's mailing address ___________________________________________________________ City, State and Zip Code ___________________________________________________________ Insurance Carrier's phone number APPLICATION FOR HEARING Industrial Accident Claim (NOTE: Include all supporting documentation when this form is filed with the Labor Commission or the Application for Hearing may be returned) I request to have a Claims Resolution Conference scheduled to resolve the issues checked below YES NO *It is the petitioner's obligation to provide the mailing address and phone number for respondent's insurance carrier. If you do not have this information you may obtain this information on the Labor Commission website, Industrial Accidents Division Workers' Compcheck or contact the employer or the Industrial Accidents Division. PETITIONER ALLEGES AND REQUESTS RESOLUTION CONCERNING THE FOLLOWING UNDER TITLE 34A: 1. 2. 3. I sustained an injury by accident arising out of and in the course of my employment with the above named employer on the following date: Month__________________Date________Year__________. The accident occurred at the following location:_________________________________________________________________ The accident occurred as follows: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ The injuries I sustained from the accident are: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Petitioner's birth date:______________________________________________ At the time of the accident at issue: my wage was $________per____________, and I was working _______hours per week. I was_______was not_______married and had ___________dependent children. 4. 5. 6. American LegalNet, Inc. www.FormsWorkFlow.com Form 001 3/1/12 APPLICATION FOR HEARING 7. A. I claim: (Please mark an "X" next to any issues you want resolved by hearing and attach relevant supporting documentation for each issue marked). Medical Expenses: (specify the providers and amounts of unpaid medical expenses): ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Recommended Medical Care: (specify services or treatment): ____________________________________________________________________________________________________________________ Temporary Total Disability Compensation: time off work from___________________ to ________________; from______________________ to _____________________; from________________________ to ____________________________. Temporary Partial Disability Compensation: reduced wages from________________ to _______________; from______________________ to _____________________; from________________________ to ____________________________. Permanent Partial Disability Compensation: (specify impairment rating(s) for each injury: ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Permanent Total Disability Compensation: permanent inability to work. (Important: you must complete the Permanent Total Disability Fact Sheet for permanent total disability compensation claims). Travel Expenses: If you claim reimbursement for travel expenses you must attach a separate sheet with the name of the medical provider, the date(s) of service, and the mileage to the provider for each date. Unpaid Interest. Other: (specify):______________________________________________________________________________________________ B. A. B. C. F. G. H. I. Petitioner verifies that the above information is true and correct to the best of petitioner's information and belief. ____________________________________________ ____________ Printed Name of Attorney for Petitioner State Bar # ___________________________________________________________ Signature of Attorney for Petitioner ___________________________________________________________ Mailing Address for Attorney for Petitioner ___________________________________________________________ City/State/Zip Code ___________________________________________________________ Telephone Number ______________________ __________________________________ FAX E-Mail Address ______________________________________ __________________ Signature of Petitioner Date ___________________________________________________________ Mailing Address of Petitioner ___________________________________________________________ City/State/Zip Code ___________________________________________________________ Petitioner's Telephone Number ___________________________________________________________ Petitioner's Social Security Number ___________________________________________________________ Petitioner's E-Mail Address American LegalNet, Inc. www.FormsWorkFlow.com Form 00
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