Utah > Workers Compensation
Employee Notification Of Denial Or Partial Denial Of Claim 089 - Utah
| Employee Notification Of Denial Or Partial Denial Of Claim Form. This is a Utah form and can be used in Workers Compensation . |
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Print Form FORM 089 EMPLOYEE NOTIFICATION OF DENIAL OR PARTIAL DENIAL OF CLAIM PLEASE PRINT OR TYPE Employee: Date of Alleged Injury:______________________ Address: Phone Number: ___________________________ City, State: Social Security: ____________________________ Employer: __________________________________ Body Part Injured: _________________________ Insurance Carrier: Date Carrier was Notified: __________________ Date of Denial: ____________________________ Claim Number: Adjustor: Adjustor's Address: ______________________________________ Adjustor's Phone Number:___________________________________ NOTICE TO THE CLAIMANT: If you are in disagreement with the denial and cannot resolve your differences by talking with the carrier and/or your treating physician, you can file for mediation and/or application for hearing. To obtain an application for mediation and/or a hearing, contact the Utah Labor Commission, Division of Industrial Accident at (801) 530-5090. Please check appropriate reason for denial (if a partial denial is issued, please refer to the section below). Fatality Failure by an employee claiming benefits to sign releases for medical information. Injury/Occupational Disease did not occur within the scope of employment. Medical information does not support the claim. Claim not filed within the statute of limitations. Claimant is not an employee. Claimant has failed to cooperate in the investigation of the claim. Pre-existing condition. Please be very specific. ______________________________________ _____________________________________________________________________________ Other A specific reason must be given. ____________________________________________ _____________________________________________________________________________ Please check appropriate reason for partial denial. Tested positive to a drug/alcohol chemical test -Medicals only paid. Disputed validity - Medicals only paid. Disputed validity - Compensation only paid. Please give a brief explanation of any item checked above: ___________________________________ __________________________________________________________________________________ LABOR COMMISSION RULE GOVERNING ACCEPTANCE/DENIAL OF A CLAIM R612-1-7. Acceptance/Denial of a Claim. (Refer to the Utah Labor Commission Workers' Compensation Rules for complete text.) A. Upon receiving a claim for workers' compensation benefits, the insurance carrier or self-insured employer shall promptly investigate the claim and begin payment of compensation within 21 days from the date of notification of a valid claim or the insurance carrier or self-insured employer shall send the claimant and the division written notice on a division form or letter containing similar information, within 21 days of notification, that further investigation is needed stating the reason(s) for further investigation. Each insurance carrier or self-insured employer shall complete its investigation within 45 days of receipt of the claim and shall commence the payment of benefits or notify the claimant and division in writing that the claim is denied and the reason(s) why the claim is being denied. B. The payment of compensation shall be considered overdue if not paid within 21 days of a valid claim or within the 45 days of investigation unless denied. C. Failure to make payment or to deny a claim within the 45 day time period without good cause shall result in a referral of the insurance company to the Insurance Department for appropriate disciplinary action and may be cause for revocation of the self-insurance certification for a self-insured employer. Copies must be sent to: Labor Commission, Employee Official Form 089 Revised 7/11 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com
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