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Application For Hearing (Occupational Disease Claim) 026 - Utah
|Application For Hearing (Occupational Disease Claim) Form. This is a Utah form and can be used in Workers Compensation .||
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Form 026 2/08 State of Utah - Labor Commission Division of Adjudication 160 East 300 South, 3rd Floor, P.O. Box 146615 Salt Lake City, Utah 84114-6615 (801) 530-6800 laborcommission.utah.gov Note: PLEASE TYPE OR PRINT IN BLACK INK APPLICATION FOR HEARING Occupational Disease Claim If you were employed for less than one year at your last employer where the injurious exposure occurred, you must file a separate Application for Hearing for each previous employer where you suffered an injurious exposure. (NOTE: Include all supporting documentation when this form is filed with the Labor Commission or the Application for Hearing may be returned.) I request to have a Claims Resolution Conference scheduled to resolve the issues checked below. ________________________________________________ Petitioner (Injured Worker) ________________________________________________ Other name(s) used by petitioner (Injured Worker) Vs. ________________________________________________ Respondent (Employer) ________________________________________________ Respondent's mailing address ________________________________________________ City, State and Zip Code ________________________________________________ Respondent's phone number ________________________________________________ Respondent's worker's compensation insurance carrier YES NO PETITIONER ALLEGES AND REQUESTS RESOLUTION CONCERNING THE FOLLOWING UNDER TITLE 34A: 1. I sustained an injury by injurious exposure arising out of and in the course of my employment with the above named employer, which injurious exposure occurred from Month _____ Date _____ Year_____ to Month _____ Date _____Year_____ The injurious exposure occurred at the following location:___________________________________ The injurious exposure resulted from either the following repetitive work activities, or harmful substances:__________________________________________________________________________ ___________________________________________________________________________________ The injuries I sustained from the accident are: ______________________________________________ ___________________________________________________________________________________ Petitioner's birth date: ______________ At the time of the accident at issue my wage was $______ per _________, and I was working _______ hours per week. I was ____was not _____ married and had ______dependent children. 2. 3. 4. 5. 6. American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR HEARING 7. I claim: (Please mark an "X" next to any issues you want resolved by hearing and attach relevant supporting documentation for each issue marked. A. Medical Expenses: (specify the providers and amounts of unpaid medical expenses):_______________ _____________________________________________________________________________________ B. Recommended Medical Care: (specify services or treatment):__________________________________ _______________________________________________________________________________________ Temporary Total Disability Compensation: time off work from _________ to_________; from _______ to _________ from _________ to: ________. C. D. E. Temporary Partial Disability Compensation: to _________; from _________ to: ________. reduced wages from _________ to_________; from _______ Permanent Partial Disability Compensation: (specify impairment rating(s) for each injury: _____________ ________________________________________________________________________________________ Permanent Total Disability Compensation: permanent inability to work. (Important - you must complete the Permanent Total Disability Fact Sheet for permanent total disability compensation claims.) Travel Expenses. (If you claim reimbursement for travel expenses you must attach a separate sheet with the name of the medical provider, the date(s) of service, and the mileage to the provider for each date.) Unpaid Interest. Other (specify):____________________________________________________________________ F. G. H. I. Petitioner verifies that the above information is true and correct to the best of petitioner's information and belief. ____________________________________________ Printed Name of Attorney for Petitioner State Bar # ____________________________________________ Signature of Attorney for Petitioner ____________________________________________ Mailing Address for Attorney for Petitioner ____________________________________________ City/State/Zip Code (___)_______________________________________ Telephone Number (___)_______________________________________ FAX E Mail Address ____________________________________________ Signature of Petitioner Date ___________________________________________ Mailing Address of Petitioner ____________________________________________ City/State/Zip Code (______)____________________________________ Petitioner's Telephone Number ____________________________________________ Petitioner's Social Security Number American LegalNet, Inc. www.FormsWorkflow.com DOCUMENTS THAT MUST BE FILED WITH APPLICATION FOR HEARING IMPORTANT: Failure to include completed and signed forms with all requested supporting documentation will result in the Application for Hearing being returned for completion. If the returned Application for Hearing is not completed and refiled with the requested supporting documents within sixty (60) days, the Application for Hearing will be dismissed. 1. 2. 3. 4. 5. Form 308A, "Medical Treatment Provider List." (If you need additional space to list all medical providers you may attach an additional sheet.) Form 309A, "Authorization to Disclose, Release, Use Protected Health Information." (HIPAA Compliant.) Form 113, "Summary of Medical Record." (Petitioner may submit other medical records that provide medical support for the claims of petitioner.) Form 152, "Appointment of Counsel." (Only required if petitioner is represented by an attorney.) Permanent Total Disability Fact Sheet. (Only required if the claim is for permanent total disability compensation.) If you know the name and address of the adjuster or third party administrator that you have dealt with concerning your claim please include that information: ___________________________________________________ Name of adjuster or third party administrator ___________________________________________________ Mailing address for adjuster or third party administrator ___________________________________________________ City/State/Zip Code American LegalNet, Inc.