Fill and Sign the Form 025 3112

Form 025 3/1/12 State of Utah ‐ Labor Commission Adjudication Division 160 East 300 Sout O. Box 146615 Sal t L 6615 h, 3 rd Floor, P. ake City, Utah 84114‐ (801) 530‐6800 casefiling@utah.gov Note: PLEASE TYPE OR PRINT IN BLACK INK APPLICATION FOR HEARING ‐DEPENDENT’S BENEFITS and/or BURIAL BENEFITS Industrial Accident Claim (NOTE: Include all supp orting documentation when this form is filed wi th 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  YES  NO Petitioner Decedent vs. Respondent (employer) dress Respondent’s mailing ad City, State and Zip Code Respondent’s phone number ce Carrier Respondent’s workers’ comp Insuran ing address Insurance Carrier’s mail City, S tate and Zip Code Insurance Carrier’s phone number PETITIONER UNDER TITLE 34A APPLIES FOR DEPENDENT’S BENEFITS and/or BURIAL ALLOWANCE, AND ALLEGES: 1. That decedent sustain rising out of and in the course of t’s employme th the e named e ployer on the following date: ed a fatal injury by accident a deceden nt wi a bov m ear . Month Date Y 2. The accident occurred as follows: 3. The cause of death was: 4. The decedent’s date of death was: Month Date Year 5. At the time of the industrial accident at issue: the decedent’s wage was $ __________ per , and decedent was working _______hours per week. Decedent was______was not______ma rried and had _________ dependent children. Form 025 3/1/12 6. The decedent had the following dependents at the time of the industrial accident at issue: NAME RELATIONSHIP BIRTH DATE PRESENT ADDRESS SOCIAL SECURITY NUMBER 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 Petitioner Date Signature of Attorney for Petiti oner Mailing Address of Petitio ner Mailing Address for Attorney for Petitioner City/State/Zip Code City/State/Zip Code Petitioner’s Telephone Number Telephone Number Petitioner’s Social Security Number FAX E‐Mail Address Petitioner’s E‐Mail Address Form 025 3/1/12 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 returnedfor completion. If the returned Application for Hearing is not completed and re ‐filed with the requested supporting documents within sixty (60) days, the Application for Hearing will be dismissed. 1. Decedent’s Death Certificate. elationship with the decedent. 2. Documents supporting dependency r 3. Minor Dependents’ birth certificates. 4. Guardianship or Conservatorship Documents for Petitioner. (Only required if filing on behalf of minor children other than petitioner’s own children) . 5. Form 152 Appointment of Counsel. (Only required if petitioner is represented by an attorney). 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 adj uster or third party administrator Mailing Address for adjuster or third party administrator C ity/State/Zip Code E‐mail Ad dress