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Insurance Companys And Self Insurers Final Report Of Injury And Statement Of Total Losses 130 - Utah
| Insurance Companys And Self Insurers Final Report Of Injury And Statement Of Total Losses Form. This is a Utah form and can be used in Workers Compensation . |
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Print Form Form 130 INSURANCE COMPANY'S AND SELF INSURER'S FINAL REPORT OF INJURY AND STATEMENT OF TOTAL LOSSES PLEASE PRINT OR TYPE INSTRUCTIONS: This final report MUST BE FILED as soon as possible, but not later than thirty (30) days after final payments are made in all workers' compensation cases. (Form 219 is also filed in all cases of permanent impairment.) List ALL medical payments made, even if reimbursed by the Employers' Reinsurance Fund. This form is to be filed when an Order is entered. .................................................................................................................................................................................. Employer's Name:______________________________________________________________________ Employer's Address: ________________________________________________ Zip: _______________ Employee's Name: ___________________________ Date of Injury: ______________________________ Employee's Social Security Number: ________________________________ When was employee physically able to return to work?_____________________________ Light Duty/Part-Time: _______________________________ Full duty____________________________ (Indicate Period of Time) Actual number of days injured was absent from work: _________________________________ Please list part of body injured: _______________________________ PAYMENTS Temporary Total for: Temporary Partial: Permanent Partial: Survivor Benefits for: __________ weeks at weeks at weeks at weeks at Medical: Vocational Rehabilitation: Travel Expenses and per diem: Date of this report: ________________________________________ Insurance Company TOTAL: $________ $ $ for a total of $__________ for a total of $__________ $_______ for a total of $__________ $ for a total of $__________ $_________ $_________ $_________ ________________________________________ Adjusting Firm ________________________________________ Signature of Adjuster ________________________________________ Adjuster's Mailing Address Printed Name of Adjuster ________________________________________ Adjuster's Phone Number Mail the original of this form to the employee and a copy to the Labor Commission Official Form 130 Revised 2/09 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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