Utah > Workers Compensation
Code 5606 Questionnaire - Utah
| Code 5606 Questionnaire Form. This is a Utah form and can be used in Workers Compensation . |
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Workers Compensation Fund Code 5606 Questionnaire Please Print or Type 1 NAME AND JOB DUTIES Give Exact or Full Name Duties Give Exact or Full Name Duties Give Exact or Full Name Duties 2 INFORMATION Does the individual(s) classified under code 5606 have direct charge of site workers? Does the individual(s) classified under code 5606 exercise indirect supervision through foreman or crew leader for insured's employees or subcontractors? Does the individual(s) classified under code 5606 do any of the construction work at any time? (If yes, provide details.) Yes No Yes No Yes No Signature and Title of Owner, Partner, Member or Corporate Officer Date Print or Type Name of Insured Policy Number Please return a completed signed application to: Workers Compensation Fund Attn. Underwriting Department 392 East 6400 South Salt Lake City, Utah 84107 If you have any questions, please call 801.8020 or 800.446.2667 ext. 8020 Fax: 801.288.8554 For your protection, Utah law requires the following to appear on this form: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in the state prison. American LegalNet, Inc. www.FormsWorkFlow.com
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