Fill and Sign the Workers Comp Formsdepartment of Labor

Form 142 STATEMENT OF INSURANCE CARRIER OR SELF-INSURER WITH RESPECT TO DI SCONTINUANCE OF BENEFITS (Employee notification of the disc ontinuance of weekly compensation benefits) rm 142 STATEMENT OF INSURANCE CARRIER OR SELF-INSURER WITH RESPECT TO DISCON TINUANCE OF BENEFITS (Employee notification of the discontinuance of weekly compensation benefits) STATEMENT OF INSURANCE CA RRIER OR SELF-INSURER WITH RESPECT TO DISCON TINUANCE OF BENEFITS Rule R612-100-3(E) of the Labor Commission workers' compensation rules require that this form must be mailed to the employee and filed with the Labor Commission five (5) days before the date compensation stops for any reason. Employee __ ________________________________ Date of Injury _______________________________ Address ___________________ ________________ Phone _____________________________________ ___________________________________ Social Security Number ______________________ Employer ____________________________________________________________________________________ Insurance Carrier ______________ _____________ Date of Filing_________________ _______________ Adjustor __________________________________ Phone Number ______________________________ Date Reasons for Suspension Effective: _______ Doctor has not filed supplemental reports. _______ Claimant moved and failed to inform carrier of new address. _______ Claimant left State and changed doctors without permission. _______ Claimant changed doctors without permission. _______ Claimant has failed to keep doctor appointment(s). _______ Claimant refuses to be seen for independent evaluation. _______ Other _________________________________ ____ __________________________________ ____ __________________________________ NOTICE TO THE CLAIMANT : If you are in disagreement with the carrier and cannot resolve your differences by talking with the car rier and/or your treating physician, you should then call the Labor Commission, Division of Industrial Acci dents, for further instructions. You may have additional benefits due, if you have sustained permanent loss of body func tion due to your industrial injury. Please check with your physician. If your physic ian has given you a permanent partia l rating, the rating needs to be sent to the adjuster listed at the top of this form. * * * IF YOU BELIEVE THAT YO U ARE ENTITLED TO UNEMPLOYMENT BENEFITS AFTER THE SUSPENSION OF WORKERS' COMPENSATION BENEFITS, YOU MUST FILE WITHIN 90 DAY S OF THE DATE OF YOUR RELEASE TO RETURN TO WORK . * * * NOTICE TO INSURANCE CARRIER/EMPLOYER : This form is to be mailed to the doctor, if the doctor is involved in any way with suspension of temporary total disability compensation. Benefits should continue until 5 days after the mailing of this form to the Applicant and the Labor Commission. ADJUSTOR: If claimant has been released to return to work, Form 110 “Release to Return to Work” must be sent to the Labor Commission and th e injured worker within five (5) calendar days of release for work. Per Rule R612-300-2(D) (1). Limitation on injured worker’s right to change physicians. An injured worker may change health care providers one time without obtaining permission of the payor … (refer to rule for complete text). Official Form 142 Revised 10/14 State of Utah * Labor Commission * Division of Industrial Accidents 160 East 300 South * P.O. Box 146610 Salt Lak e City, UT 84114-6610 * Telephone: 801- 530-6800 Fax: 801- 530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov