Fill and Sign the Forms Workers Compensation Industrial Accidents Utah

CLAIMANT INFORMATION EMPLOYER INFORMATION INSURANCE CARRIER INFORMATION FORM 401 5/2001 STATE OF UTAH LABOR COMMISSION DIVISION OF INDUSTRIAL ACCIDENTS P.O. BOX 146610, 160 E 300 SO, SALT LAKE CITY, UT 84114-6610 (801)530-6800 (800)530-5090 (TTD)530-7685 FAX 530-6804 REQUEST FOR CLAIMS RESOLUTION CONFERENCE NAME _____ DATE OF INJURY ____________________________ SS NUMBER __________________________ PHONE NUMBER ______________________________ ADDRESS _____________________________ STREET ___________________________ CITY, STATE, ZIP HAVE YOU RETAINED AN ATTORNEY TO ASSIST YOU WITH YOUR CLAIM ? YES NO *THE LABOR COMMISSION NEITHER REQUIRES NOR DISCOURAGES LEGAL REPRESENTATION IN THE PURSUIT OF A WORKERS COMPENSATION CLAIM. NAME __ PHONE NUMBER ______________________________ ADDRESS ____________________________ STREET __________________________ CITY, STATE, ZIP NAME _ PHONE NUMBER _____________________________ ADDRESS _ ADJUSTOR _________________________________ STREET (IF KNOWN) CITY, STATE, ZIP ISSUES NEEDING RESOLUTION: 1. _____________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ - If more room is needed, please use the back of this form. - I REQUEST TO HAVE A CLAIMS RESOLUTION CONFERENCE SCHEDULED TO RESOLVE THE ABOVE ISSUES. REQUESTOR’S SIGNATURE _______________ PHONE NUMBER ________DATE _____________ Requestor’s relationship to claim ____ Employee ____ Adjustor ____ Applicant’s Counsel ____ Defense Counsel ____ Other (Please specify) ______________________________________________ Your Claims Resolution Conference will be scheduled within 14 days from the time the Division of Industrial Accidents receives agreement from both parties to participate in this process. CASE NUMBER