Fill and Sign the Get the Form 141 Initial Statement of Insurance Carrierself

Form 141 INITIAL STATEMENT OF INSURANCE CARRIER OR SELF-INSURER WITH RESPECT TO PAYMENT OF BENEFITS PLEA SE PRINT OR TYPE Origina l □ Amended □ Reason(s) for Amendment Total Cu m ulative Lost W ork Days Due to this In jury Employee Survivor Address Date Carrier Notified of Lost Time Employee Phone Social Security Nu mb er Please list part of body injured Claim Number Claim is for a FATALITY □ Date of Inju ry (List Fatality Dependent(s) as an Addendum) Claim is for Injury □ Employer Claim is for Occupational Disease □ Address City, State, ZI P COMPUTATION OF BENEFIT RAT E Basic Rate of Pay (Specify wheth er per hr/day/week/month) $ Basic Benefit Rate (2 /3 of Gross Avg. Weekly Wage not to exceed Maxim um) = $ $5.00 dependency allowance for spouse and dependent children $ Amoun t of weekly bene fit (Basic + Dep. All owance) = $ The Maximum =100% State Average Weekly Wage: Dependent s' 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 c an the weekly benefits exceed the m aximu m, or be less than the m inimum of $45.00 per week. The maximum up to Ju ly 1, 2012 to June 30, 2013 -- $762.00, J uly 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 mo re are missed. First check for weeks days from to in the amount of was mailed on . Insurance Carri er Phone Adjustor Adjustor’s Sign ature (Type or Prin t) Adjustor’s Address (Street / PO Box) (Pho ne Nu mb er) (City, Stat e, Zip) “Statement of Insurance Carrier or Self Insured with Respect to Pa yment of Benefits – Form 141” - This form i s used for reporting the in itial benefits paid to an injured employ ee. This form mu st be filed with or mailed to th e Labor Commission on the same date the first payment of compensation is mailed to the employee. A copy of this form mu st accompany the first payment. NOTICE TO EMPLOYEE Travel Rei mbursement for Medical Care: You may be eligible for reimbursement for travel to and from medical care which has been authorized by the insurance carri er (per Rule R612-300-8). You will need to contact your insurance adjuster. Official Form 141 Revised 07/17 State of Ut ah * Labor Commission * Division of Industrial Accidents 160 East 300 South * P.O. Box 146610 Salt Lake City, UT 84114-6610 * Te lephone: 8 01-530-68 00 Fax: 801- 530-6804 * Toll Free: ( 800) 530-5090 * www.laborcommiss ion.utah.g ov