Utah > Workers Compensation
Initial Statement Of Insurance Carrier Or Self Insurer With Respect To Payment Of Benefits 141 - Utah
| Initial Statement Of Insurance Carrier Or Self Insurer With Respect To Payment Of Benefits Form. This is a Utah form and can be used in Workers Compensation . |
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Print Form Form 141 INITIAL STATEMENT OF INSURANCE CARRIER OR SELF-INSURER WITH RESPECT TO PAYMENT OF BENEFITS PLEASE PRINT OR TYPE Original Amended Reason(s) for Amendment ________________________________________ Total Cumulative Lost Work Days Due to this Injury__________________________________________ Employee _________________________ Survivor _________________________ Address _________________________ _________________________ Date Carrier Notified of Lost Time ______________________ Employee Phone _____________________________________ Social Security Number _______________________________ Please list part of body injured __________________________ Claim Number __________________ Date of Injury _____________________________________ Claim is for a FATALITY (List Fatality Dependent(s) as an Addendum) Claim is for Injury Employer __________________________________________ Claim is for Occupational Disease Address ____________________________________________ City, State, ZIP______________________________________ COMPUTATION OF BENEFIT RATE Basic Rate of Pay (Specify whether per hr/day/week/month) ________________ $_______________ Basic Benefit Rate (2/3 of Gross Avg. Weekly Wage not to exceed Maximum) $5.00 dependency allowance for spouse and dependent children Amount of weekly benefit (Basic + Dep. Allowance) = $_______________ $_______________ = $_______________ The Maximum =100% State Average Weekly Wage: Dependents' benefits of $5.00 for spouse and $5.00 for each dependent minor child under 18 (up to 4) is added to reach maximum, but at no time can the weekly benefits exceed the maximum, or be less than the minimum of $45.00 per week. The maximum up to July 1, 2007 to June 30, 2008 -- $665.00, July 1, 2009 to June 30, 2010 -- $720.00, July 1, 2010 to June 30, 2011 -- $732.00, July 1, 2011 to June 30, 2012 -- $747.00. The first 3 days are not compensable unless 15 days or more are missed. weeks days from to in the amount of $________ First check for was mailed on ___________________. Insurance Carrier _______________________________ Phone _______________________________ Adjustor ____________________________ Adjustor's Signature ______________________________ (Type or Print) Adjustor's Address _____________________________________________________________________ (Street / PO Box) (Phone Number) (City, State, Zip) "Statement of Insurance Carrier or Self Insured with Respect to Payment of Benefits Form 141" - This form is used for reporting the initial benefits paid to an injured employee. This form must be filed with or mailed to the Labor Commission on the same date the first payment of compensation is mailed to the employee. A copy of this form must accompany the first payment. NOTICE TO EMPLOYEE Travel Reimbursement for Medical Care: You may be eligible for reimbursement for travel to and from medical care which has been authorized by the insurance carrier (per rule R612-2-20). You will need to contact your insurance adjuster. Official Form 141 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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