Utah > Workers Compensation
Request For Claims Resolution Conference 401 - Utah
| Request For Claims Resolution Conference Form. This is a Utah form and can be used in Workers Compensation . |
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FORM 401 as of 05/0 1 STATE OF UTAH LABOR COMMISSION DIVISION OF INDUSTRIAL ACCIDENTS P.O. BOX 146610, 160 E 300 SO, SALT LAKE CITY, UT 84114-6610 (801)530-6800 (800)530-5090 (TTD)530-7685 FAX 530-6804 REQUEST FOR CLAIMS RESOLUTION CONFERENCE EMPLOYEE INFORMATION NAME: DATE OF INJURY: SS #: PHONE #: ADDRESS: STREET CITY, STATE, ZIP HAVE YOU RETAINED AN ATTORNEY TO ASSIST YOU WITH YOUR CLAIM ? YES NO *THE LABOR COMMISSION NEITHER REQUIRES NOR DISCOURAGES LEGAL REPRESENTATION IN THE PURSUIT OF A WORKERS COMPENSATION CLAIM. EMPLOYER INFORMATION NAME: PHONE #: ADDRESS: STREET CITY, STATE, ZIP INSURANCE CARRIER INFORMATION NAME: PHONE #: ADDRESS: ADJUSTOR: STREET (IF KNOWN) CITY, STATE, ZIP ISSUES NEEDING RESOLUTION: 1 . 2. 3. - If more room Is needed, please use the back of this form. - I REQUEST TO HAVE A CLAIMS RESOLUTION CONFERENCE SCHEDULED TO RESOLVE THE ABOVE ISSUES. REQUESTORS SIGNATURE: Phone # Date: Requestors relationship to claim: Employee Employer Adjustor Applicants Counsel Defense Counsel Other (Please specify): Your Claims Resolution Conference will be scheduled within 14 days from the time the Division of Industrial Accidents receiveagrs eement from both partiesto participate In this process. CASE NUMBER
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