Utah State Government Forms

Form Title	Agency	Topics
001 Industrial Accident Claim – Form Instructions	Department of Labor Commission
024 Medical Care Provider	Department of Labor Commission
025 Industrial Accident Claim	Department of Labor Commission
026 Occupational Disease Claim – Form Instructions	Department of Labor Commission
027 Occupational Disease Claim – Form Instructions	Department of Labor Commission
113a Summary of Medical Record – Industrial Accident (or you may submit actual medical records supporting your claim)	Department of Labor Commission
113b Summary of Medical Record – Occupational Exposure	Department of Labor Commission
1391 Instructions	Department of Transportation	Construction, Appendix / Toolbox, Appendix / Toolbox
1444 Instructions	Department of Transportation	Construction, Appendix / Toolbox, Appendix / Toolbox
152 Appointment of Counsel	Department of Labor Commission
2018 Medical Fee Standards	Department of Labor Commission
2018 Workers’ Compensation Quick Reference Guide	Department of Labor Commission
2019 Medical Fee Standards	Department of Labor Commission
2019 Workers’ Compensation Payment Grid	Department of Labor Commission
2019 Workers’ Compensation Quick Reference Guide	Department of Labor Commission
307 Medical Treatment Provider List	Department of Labor Commission
308 Authorization to Release Medical Records	Department of Labor Commission
30 Day ATMS BURN-IN TEST REPORT	Department of Transportation	Construction, Inspection
402 Application for Hearing – Termination or Reduction of Compensation	Department of Labor Commission
403 Persons with Knowledge List	Department of Labor Commission