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Form 441 INSURANCE CARRIERS / SELF INSURER’S NOTICE OF FURTHER INVESTIGATION OF A WORKERS’ COMPENSATION CLAIM PLEA SE PRINT OR TYPE Employ ee Phone Nu mber Address Date of Injury City, State, Zip Social Security Number Employer Insurance Carrier Date Carrier was Notified Adjustor Phone Nu mber Adjuster is actively: Date Requested Requesting information from medical provider Obtaining statement from injured worker and/or witness Requesting signed medical release from injured employee Other (Please be Specific) R612-200-1. Reporting and Investigating Injuries. C. Investigation of Claims; Notice to Division and Claimants; Commencement of Benefits. 1. An insurance carrier, self-insured employer, or uninsured employer shall promptly investigate a reported work injury and either accept or deny workers’ compensation liability for the claim within 21 days after receiving initial notice of injury. a. If, with reasonable diligence, an insurance carrier, self-insured employer, or uninsured employer cannot co mplete its investigation within 21 days after initial notice, it may complete an submit Division Form 441, “Notice of Further Inves tigation of Workers’ Compensation Claim ” notify the Division and claimant that the matter remains under investigation. The insurance carrier, self-insured employer, or uninsured employer is then allowed 24 days in addition to the initial 21-day period to complete its investigation and accept or deny liability of the claim. d. An insurance carrier, self-insured employer, or uninsured employ er’s payment of benefits during investigation of a claim does not prevent subsequent denial of the claim after the investigation is completed. D. Co nsequences of Failure to Comply. 1. Pursuant to Subsection 34A-2-407(8) of the Utah Workers ’ Compensation Act, the Division may impose a civil assessment of up to $500 for an insurance carrier, insured employer, or self-insured employer, or uninsured employ er’s failure, without good cause, to comply with the requirements of this rule. a. “Good C ause” includes a clai mant’s unreasona ble failure to sign requested medical releases or otherwise cooperate in the investigation of a claim. cc: Labor Commission, Employ ee Official Form 441 Revised 10/14 State of Ut ah * 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.g ov