Utah State Government Forms

Form Title	Agency	Topics
001 Industrial Accident Claim – Form Instructions	Department of Labor Commission
001 Industrial Accident Claim – Form Instructions	Occupational Safety & Health
024 Medical Care Provider	Department of Labor Commission
024 Medical Care Provider	Occupational Safety & Health
025 Industrial Accident Claim	Department of Labor Commission
025 Industrial Accident Claim – Form Instructions	Occupational Safety & Health
026 Occupational Disease Claim – Form Instructions	Department of Labor Commission
026 Occupational Disease Claim – Form Instructions	Occupational Safety & Health
027 Occupational Disease Claim – Form Instructions	Department of Labor Commission
027 Occupational Disease Claim – Form Instructions	Occupational Safety & Health
113a Summary of Medical Record – Industrial Accident	Occupational Safety & Health
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
113b Summary of Medical Record – Occupational Exposure	Occupational Safety & Health
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
152 Appointment of Counsel	Occupational Safety & Health
2018 Medical Fee Standards	Department of Labor Commission
2018 Workers’ Compensation Quick Reference Guide	Department of Labor Commission