Utah > Workers Compensation
Application For Lump Sum Or Advance Payment 134 - Utah
| Application For Lump Sum Or Advance Payment Form. This is a Utah form and can be used in Workers Compensation . |
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Form 134 8/10 STATE OF UTAH - LABOR COMMISSION Division of Adjudication P. O. Box 146615 Salt Lake City, UT 84114-6615 (801) 530-6800 Fax (801)530-6333 casefiling@utah.gov * Name of Employee (printed) Date of Injury Name of Employer (printed) Workers' Compensation Insurance Company of Employer * * * * * * * APPLICATION FOR LUMP SUM OR ADVANCE PAYMENT UNACCRUED AMOUNTS WILL BE SUBJECT TO A DISCOUNT WHICH WILL REDUCE THE AMOUNT PAYABLE BY THE CARRIER Lump Sum payments are permitted under Section 34A-2-421, U.C.A., which states, "An administrative law judge, under special circumstances and when the same is deemed advisable, may commute periodic benefits to one or more lump-sum payments." [Emphasis added] To determine whether special circumstances exist, the administrative law judge requires answers to the following questions: NO 1. Are you employed at the present time? YES If so, name of Employer: ___________________________________________________________________________ Monthly earnings: ________________________________________________________________________________ 2. NO ______ Are you presently engaged in a vocational rehabilitation program? YES Name of Rehabilitation Counselor: ___________________________________________________________________ NO ______ Is your spouse employed? YES If so, name of employer: ___________________________________________________________________________ Number of children under 18 living at home: _________ List monthly obligations such as rent, food utilities, car payments. Use other side, if necessary. ___________________ _______________________________________________________________________________________________ Do you or your spouse receive monthly benefits from any other source? YES Amount of cash in savings account(s) or bonds: How much money are you requesting to be advanced? NO _____ 3. 4. 5. 6. 7. 8. 9. $ ___________________ $ ___________________ What are the reasons for making this request? ___________________________________________________________ ________________________________________________________________________________________________ The Undersigned hereby certifies that the information listed above is true and correct and the money requested will be used only for the purposes indicated. ..................................................................................................................................................................................................................... _______________________________________ Signature of Applicant Street Address _______________________________________ City/State/Zip Telephone Date Approved: By Administrative Law Judge Request denied for the following reasons: ______________________________________________________________ __________________________________________________________________________________________________ Date Denied By Administrative Law Judge American LegalNet, Inc. www.FormsWorkFlow.com R612. Labor Commission, Industrial Accidents. R612-1. Workers' Compensation Rules - Procedures. R612-1-4. Discount. Eight percent shall be used for any discounting or present value calculations. Lump sums ordered by the Commission or for any attorney fees paid in a single up-front amount, or of any other sum being paid earlier than normally paid under a weekly benefit method shall be subject to the 8% discounting. For purposes of calculating the 8% discount, please reference Publications R612-1-4 Present Value Table: http://www.laborcommission.utah.gov/Downloads.html#Adjudication American LegalNet, Inc. www.FormsWorkFlow.com
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