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Utah Forms

92 State Forms found

name	number	revision	print or send online
(DISCONTINUED BY STATE, NO REPLACEMENT) AUTHORIZATION TO RELEASE LABOR COMMISSION RECORDS	Form 046 - DEACTIVATED	Revised 06/2003
APPLICATION FOR SELF-INSURANCE	Official Form 109	Rev 10/2019
SUMMARY OF MEDICAL RECORD – OCCUPATIONAL EXPOSURE	Form 113b	Revised 3/2010
SELF-INSURANCE AGGREGATE SURETY BOND	Official Form 213E	Rev 10/2019
AGREEMENT OF ASSUMPTION AND GUARANTY OF WORKERS’ COMPENSATION	Official Form 215E	Rev 10/2019
UTAH BANKRUPTCY AND INSOLVENCY ENDORSEMENT	Official Form 303	Rev 10/2019
MEDICAL TREATMENT PROVIDER LIST	Form 307	Revised 01/21
Restorative Services Authorization / Denial - SPINE	Form 221a	Rev 7/2024
Restorative Services Authorization/Denial - UPPER EXTREMITY	Form 221b	Rev 7/2024
Restorative Services Authorization/Denial - LOWER EXTREMITY	Form 221c	Rev 7/2024
(DISCONTINUED BY STATE, NO REPLACEMENT) Abstract of Award	No Form Number - DEACTIVATED	No date
(DISCONTINUED BY STATE, NO REPLACEMENT) CONTINUED DEPENDENTS’ BENEFITS DECLARATION	No Form Number - DEACTIVATED	No date
(DISCONTINUED BY STATE, NO REPLACEMENT) NOTICE OF DESIGNATED AGENT	No Form Number - DEACTIVATED	4/1/11
Wage Claim Assignment Form	No Form Number	No Form/Rev Date
RENEWAL APPLICATION FOR SELF-INSURANCE	Official Form 223E	Rev 10/2019

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Disclaimer: These forms may not be the most recent version. Utah may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.

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