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Form 141 Initial Statement of Insurance Carrier

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INITIAL STATEMENT OF INSURANCE CARRIER OR SELF-INSURER WITH RESPECT TO PAYMENT OF BENEFITS

Form 141 — PLEASE PRINT OR TYPE

Reason(s) for Amendment

Total Cumulative Lost Work Days Due to this Injury

Employee

Date Carrier Notified of Lost Time

Survivor

Employee Phone

Address

Social Security Number

Claim Number

Please list part of body injured

Date of Injury

Employer

Claim is for a FATALITY

(List Fatality Dependent(s) as an Addendum)

Claim is for Injury

Claim is for Occupational Disease

Address

City, State, ZIP

COMPUTATION OF BENEFIT RATE

Basic Rate of Pay (Specify whether per hr/day/week/month) $

Basic Benefit Rate (2/3 of Gross Avg. Weekly Wage not to exceed Maximum) = $

$5.00 dependency allowance for spouse and dependent children $

Amount of weekly benefit (Basic + Dep. Allowance) = $

The Maximum =100% State Average Weekly Wage: Dependents' benefits of $5.00 for spouse and $5.00 for each dependent minor child under 18 (up to 4) is added to reach maximum, but at no time can the weekly benefits exceed the maximum, or be less than the minimum of $45.00 per week. The maximum up to July 1, 2012 to June 30, 2013 -- $762.00, July 1, 2013 to June 30, 2014 -- $782.00, July 1, 2014 to June 30, 2015 -- $790.00, July 1, 2015 to June 30, 2016 - $811.00, July 1, 2017 to June 30, 2018 $855.00. The first 3 days are not compensable unless 15 days or more are missed.

First check for weeks days from to in the amount of was mailed on

Insurance Carrier

Phone

Adjustor

(Type or Print)

Adjustor’s Signature

Adjustor’s Address (Street / PO Box) (Phone Number) (City, State, Zip)

“Statement of Insurance Carrier or Self Insured with Respect to Payment of Benefits – Form 141” - This form is used for reporting the initial benefits paid to an injured employee. This form must be filed with or mailed to the Labor Commission on the same date the first payment of compensation is mailed to the employee. A copy of this form must accompany the first payment.

NOTICE TO EMPLOYEE Travel Reimbursement for Medical Care: You may be eligible for reimbursement for travel to and from medical care which has been authorized by the insurance carrier (per Rule R612-300-8). You will need to contact your insurance adjuster.

Official Form 141 Revised 07/17
State of Utah * 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.gov

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What the Form 141 Initial Statement of Insurance Carrier Is

The Form 141 Initial Statement of Insurance Carrier is a standardized document used to record an insurer's basic identification, policy details, coverage limits, and initial underwriting information at the start of a policy relationship. It links the insurer to the insured party, establishes the effective date and policy number, and provides administrative details necessary for premium billing, claims routing, and regulatory reporting. This form often accompanies first notices of coverage or enrollment packages and serves as an official record for carriers, agents, producers, and regulated state insurance authorities.

Why accurate completion of Form 141 matters

Completing Form 141 correctly ensures accurate policy administration, speeds claims processing, and reduces the risk of regulatory inquiries. It creates a clear audit trail linking carrier decisions to the insured record.

Why accurate completion of Form 141 matters

Who completes and relies on Form 141

Several parties prepare, submit, or reference Form 141 during a policy lifecycle; the distribution differs by process and jurisdiction.

  • Insurance carriers and underwriters who record policy setup, coverage limits, and issuer contact details for underwriting and claims.
  • Agents and brokers who gather insured information and forward completed statements to carriers and regulatory filing systems.
  • Claims administrators and third-party administrators who use the initial statement to verify coverage and assign claim handling responsibilities.

Ensuring the right party completes the correct fields reduces rework and supports compliance with carrier and state reporting rules.

Core components to include on a professional Form 141

A professional Form 141 is organized, unambiguous, and contains the insurer’s official identifiers, clear coverage statements, and signature blocks that document authorization and the effective date.

Carrier ID

Official insurer name and mailing address with NAIC code where applicable; ensures regulatory and billing systems match the carrier.

Policy Reference

Policy number and internal reference codes used by the carrier and agent to track the account and link to underwriting files.

Coverage Summary

High-level description of insured risks, covered limits, deductibles, and any subject-to-underwriting conditions that affect claims handling.

Effective Dates

Policy effective and expiration dates, and any retroactive coverage or pending effective conditions that alter liability windows.

Regulatory Notices

State-specific disclaimers, filing references, or required acknowledgements that carriers must include for compliance with local insurance codes.

Signature Block

Authorized signer name, title, signature, and date indicating carrier acceptance; electronic signature metadata should be retained.

Step-by-step: completing Form 141 accurately

Follow these steps to populate Form 141 in a single pass and reduce return-for-correction cycles.

  • 01
    Gather Documents: Collect policy, underwriting memo, and carrier license details before starting.
  • 02
    Enter Carrier Data: Populate legal name, NAIC, address, and contact information precisely.
  • 03
    Record Policy Details: Add policy number, effective dates, coverage limits, and endorsements.
  • 04
    Sign and Date: Authorized representative signs; retain signature metadata and audit trail.

How the Form 141 fits into insurer workflows

Form 141 is an administrative anchor used at policy inception, then consumed by billing, claims, and compliance systems.

  • Underwriting Intake: Form serves as the official record of coverage decisions and underwriting notes.
  • Policy Administration: Billing and document management systems use the form for account setup and premium invoicing.
  • Claims Verification: Claims teams reference the form to confirm insured status and limits before payouts.
  • Regulatory Reporting: Carriers may file aggregated data to state regulators referencing information from Form 141.

Configuring a digital workflow for Form 141

Map form fields to downstream systems and define signer order to ensure consistent routing and auditability.

Field Configuration
Carrier ID Required, map to billing and regulatory fields
Policy Number Required, validate format with regex
Effective Date Required, datepicker MM/DD/YYYY
Signature Required, capture audit trail and signer IP

Technical considerations for eSubmission

Choose a platform that supports secure fields, audit trails, and the integrations your carrier ecosystem needs.

  • File formats: PDF, DOCX supported for upload and signing
  • Integrations: Connectors for CRM, policy admin, and cloud storage
  • Authentication: Email, SMS, or advanced signer authentication

Ensure the platform meets any industry compliance needs (for example HIPAA BAA if health information is present) and captures a complete audit trail for defensible records.

Essential data elements required on Form 141

Carrier Name: Full legal name
Carrier NAIC: Numeric NAIC ID
Policy Number: Carrier policy ID
Effective Date: MM/DD/YYYY
Coverage Limits: Numeric currency
Authorized Signer: Name and title

Consequences of incorrect or incomplete Form 141

Claim Delays: Payment hold or investigation
Coverage Denial: Potential denial for inaccurate disclosures
Regulatory Fines: State penalties or corrective orders
Audit Exposure: Increased regulatory scrutiny
Contract Disputes: Disagreement on limits or effective date
Privacy Violation: HIPAA or data breach consequences

Common preparation mistakes and how they affect outcomes

  • Entering a trade name instead of the carrier's legal name can break automated matching and delay billing reconciliations and regulatory filings.
  • Using ambiguous or inconsistent policy numbers prevents correct linkage to claims files and causes manual research requests across teams.
  • Failing to capture the effective date in MM/DD/YYYY format can create disputes over coverage windows and may affect claim adjudication.
  • Submitting unsigned or improperly authenticated forms forces re-execution, slows onboarding, and can trigger compliance review by regulators.

Timing and processing expectations for Form 141

Timelines vary by carrier and state; plan for immediate entry at policy issuance and keep records to meet retention and reporting obligations.

At Issuance:

Complete Form 141 when the policy is bound or within carrier-defined timeframe

Claims Reference:

Provide the form to claims within 24–72 hours upon receipt of a claim

Regulatory Filing:

Follow carrier and state timing; some state filings are quarterly or ad hoc

Audit Retention:

Retain original records per federal and state rules

Correction Window:

Correct material errors as soon as discovered to limit exposure

Key milestones from form completion to archive

This sequential view highlights major stages after Form 141 is executed and how each stage advances the policy lifecycle.

01

Form Completion

Carrier and agent complete and sign the initial statement.

02

System Entry

Form data is entered or ingested into policy administration systems.

03

Claims Availability

Claims teams gain access to coverage details for adjudication.

04

Retention & Audit

Record archived and retained according to legal retention periods.

eSignature pricing and capability comparison for Form 141 eSubmission

Compare vendors on starting price, trial options, bulk send, audit trail, HIPAA compliance, and envelope caps to match your volume and compliance needs.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/yr Varies Varies Varies

Frequently asked questions about Form 141

Answers to common questions about completion, eSigning, who signs, and recordkeeping for Form 141.


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