Utah > Workers Compensation
Statement Of Insurance Carrier Or Self Insurer With Respect To Discontinuance Of Benefits 142 - Utah
| Statement Of Insurance Carrier Or Self Insurer With Respect To Discontinuance Of Benefits Form. This is a Utah form and can be used in Workers Compensation . |
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Print Form Form 142 STATEMENT OF INSURANCE CARRIER OR SELF INSURER WITH RESPECT TO DISCONTINUANCE OF BENEFITS (Employee notification of the discontinuance of weekly compensation benefits) PLEASE PRINT OR TYPE *Rule R612-1-3(G) of the Labor Commission workers' compensation rules require that this form must be mailed to the employee and filed with the Labor Commission five (5) days before the date compensation stops for any reason. Employee __________________________________ Address ___________________________________ ___________________________________ Date of Injury _________________________________ Phone ________________________________________ Social Security Number __________________________ Employer___________________________________________________________________________________ Insurance Carrier ___________________________ Adjustor __________________________________ Date of Filing _________________________________ Phone Number ________________________________ Date Reasons for Suspension Effective: _____________________ Doctor has not filed supplemental reports. Claimant moved and failed to inform carrier of new address. Claimant left State and changed doctors without permission. Claimant changed doctors without permission. Claimant has failed to keep doctor appointment(s). Claimant refuses to be seen for independent evaluation. Other ________________________________ _____________________________________ _____________________________________ Per Rule 612-2-0. Change of Doctors and Hospitals. The employee may make one change of doctor without requesting permission of the carrier, so long as the carrier is promptly notified... NOTICE TO THE CLAIMANT: If you are in disagreement with the carrier and cannot resolve your differences by talking with the carrier and/or your treating physician, you should then call the Labor Commission, Division of Industrial Accidents, for further instructions. You may have additional benefits due, if you have sustained permanent loss of body function due to your industrial injury. Please check with your physician. If your physician has given you a permanent partial rating, the rating needs to be sent to the adjuster listed at the top of this form. *** IF YOU BELIEVE THAT YOU ARE ENTITLED TO UNEMPLOYMENT BENEFITS AFTER THE SUSPENSION OF WORKERS' COMPENSATION BENEFITS, YOU MUST FILE WITHIN 90 DAYS OF THE DATE OF YOUR RELEASE TO RETURN TO WORK. *** NOTICE TO INSURANCE CARRIER/EMPLOYER: This form is to be mailed to the doctor, if the doctor is involved in any way with suspension of temporary total disability compensation. Benefits should continue until 5 days after the mailing of this form to the Applicant and the Labor Commission. ADJUSTOR: If claimant has been released to return to work, Form 110 "Release to Return to Work" must be sent to the Labor Commission and the injured worker within five (5) calendar days of release for work. Official Form 142 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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