Application For Hearing Failure Of Diligent Pursuit {502}

Form5023/1/12 StateofUtah­LaborCommission AdjudicationDivision 160East300South3rdFloor.POBox146615 SaltLakeCity,Utah841146615 (801)5306800 casefiling@utah.gov Note:PLEASETYPEORPRINTINBLACKINK ______________________________________________________ InjuredEmployee(Petitioner) ApplicationForHearing ______________________________________________________ FailureOfDiligentPursuit Petitioner'sMailingAddress ___________________________________________________ (Note:Includeallsupportingdocumentation CityStateZipCode whenthisformisfiledwiththeLabor CommissionortheApplicationForHearing vs. maybereturned) _____________________________________________________ Respondent(Employer) _____________________________________________________ Respondent'sMailingAddress ____________________________________________________ CityStateZipCode ______________________________________________________ Respondent'sWorkers'CompInsuranceCarrier ______________________________________________________ InsuranceCarrier'sMailingAddress ____________________________________________________ CityStateZipCode ______________________________________________________ InsuranceCarrier'sPhoneNumber PETITIONER/RESPONDENTALLEGESANDREQUESTSRESOLUTIONCONCERNINGTHE FOLLOWINGUNDERTITLE34A: 1. Dateofindustrialinjury:Month________________Day__________Year_________ 2. Commission case number from order approving reemployment plan: _______________________. 3. A hearing is requested because the employer / insurance carrier has failed to diligentlypursuethereemploymentplan. 4. Thefactssupportingmyrequestareasfollows: American LegalNet, Inc. www.FormsWorkFlow.com Form5023/1/12 _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ ______________________________________________________________ CityStateZipCode _________________________________________________________________ Telephone _________________________________________________________________ Fax _________________________________________________________________ EMailAddress Ifyouknowthenameandaddressoftheadjusterorthirdpartyadministratorthatyou havedealtwithconcerningyourclaimpleaseincludethatinformation: _______________________________________________________________ Nameofadjusterorthirdpartyadministrator _______________________________________________________________ MailingAddressforadjusterorthirdpartyadministrator _________________________________________________________ CityStateZipCode _____________________________________________________________ EMailAddress Petitioner/Respondentverifiesthattheaboveinformationistrueandcorrecttothebest ofpetitioner's/respondent'sinformationandbelief. ________________________________________ ____________________________________________________________ SignatureofPetitioner/Respondent PrintedNameofAttorneyforPetitioner/Respondent _________________________________________ ____________________________________________________________ Date StateBar# _________________________________________ ____________________________________________________________ Petitioner'sPhoneNumber SignatureofAttorneyforPetitioner/Respondent _________________________________________ _____________________________________________________________ MailingAddressforAttorneyforPetitioner/Respondent Petitioner'sSocialSecurityNumber American LegalNet, Inc. www.FormsWorkFlow.com