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Get Form 122 Utah

ST REPORT OF INJURY OR ILLNESS STATE OF UTAH - THE LABOR COMMISSION - DIVISION OF INDUSTRIAL ACCIDENTS 160 E 300 S, P.O. BOX 146610 SALT LAKE CITY, UTAH 84114-6610 G E N E R A L EMPLOYER (Name & Address Incl. Zip) CARRIER/ADMINISTRATOR CLAIM NUMBER OSHA LOG NUMBER REPORT PURPOSE CODE JURISDICTION JURISDICTION CLAIM NUMBER INSURED REPORT NUMBER EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT) INDUSTRY CODE LOCATION # EMPLOYER FEIN PHONE # CARRIER/CLAIMS ADMINISTRATOR C L CARRIER (NAME, ADDR.

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