Get Form 122 Pdf 2020-2025

Filling out the Form 122 Pdf is an essential process for reporting a worker’s compensation injury or illness in Utah. This guide provides clear, step-by-step instructions to help users complete the form efficiently and accurately.

Follow the steps to fill out the Form 122 Pdf online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by filling in the employer's name and address, ensuring all fields are complete and accurate, including the zip code.
3. Provide the carrier or administrator's claim number, followed by the general jurisdiction claim number.
4. Enter the employer's location address if it differs from the main address entered earlier.
5. Complete the employer's federal employer identification number (FEIN) and contact phone number.
6. Fill out the claims administrator’s name, address, and phone number correctly.
7. Indicate if the employer is self-insured and provide the appropriate policy number.
8. Input the employee's personal details, including name, date of birth, social security number, address, and marital status.
9. Document the date of injury or illness, time of occurrence, and the type of injury or illness.
10. Include information about the injury's nature, body parts affected, and whether it happened on the employer's premises.
11. Detail the cause of the injury or the specific activity during which it occurred, along with any relevant equipment or substances involved.
12. If applicable, provide the physician or health care provider's information and any treatment received.
13. Finally, review all entered information for accuracy, save your changes, and then choose to download, print, or share the completed form as needed.

Start completing your document online today to ensure timely and accurate reporting.