Notice Of Filing Application For Hearing For Termination Or Reduction Of Compensation {404}

Form 404 3.1.12 UtahLaborCommission Adjudication Division 160East300South,3rdFloor,P.O.Box146615 SaltLakeCity,Utah841146615 (801)5306800 casefiling@utah.gov Note:PLEASETYPEORPRINTINBLACKINK Employer(Petitioner) Employer'sMailingAddress City,StateandZipCode Employer'sEMailAddress Petitioner'sWorkers'CompInsuranceCarrier InsuranceCarrier'sMailingAddress City,StateandZipCode InsuranceCarrier'sEMailAddress vs. Respondent(Employee) Respondent'sMailingAddress City,StateandZipCode Respondent'sPhoneNumber NOTICEOFFILINGAPPLICATIONFOR HEARING FORTERMINATIONORREDUCTIONOF COMPENSATION PetitionerherebynotifiesrespondentthatanApplicationforHearingforTerminationorReduction ofCompensationhasbeenfiledwiththeUtahLaborCommission. ThisapplicationforhearingrequeststheCommissionto: _________Terminatetemporarytotaldisabilitycompensation _________Reduceweeklytemporarytotaldisabilitycompensationby$ __________________________ AhearingwillbescheduledbytheAdjudicationDivisionoftheCommissionwithin30daysoffiling thisApplication. American LegalNet, Inc. www.FormsWorkFlow.com Form 404 3.1.12 PrintedNameofAttorneyforPetitionerStateBar# SignatureofAttorneyforPetitioner Attorney'sMailingAddress City TelephoneNumber FAX EMailAddress State ZipCode Icertifythatonthis_______dayof ,20 _____ ,acopyoftheattachedNoticeofRequestof TerminationorReductionofCompensationinthecaseof ,Petitionervs. ,Respondent,wasmailedfirstclass,postageprepaid,to therespondentatthefollowingaddress: RespondentName RespondentAddress City State ZipCode PrintName Signature American LegalNet, Inc. www.FormsWorkFlow.com