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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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Compensation shall be 66-2/3% of the employee's average weekly wages at the time of the injury, but not more than a maximum of 66-2/3% of the state average weekly wage at the time of the injury and not less than a minimum of $45.00 per week plus $20.00* for a dependent spouse and $20.00 for each dependent child under ...

With a few exceptions, every employer is required to provide workers' compensation coverage for all its employees. Refer to Utah Code Ann. §34A-2-201. The Utah Department of Insurance establishes basic premium rates.

When a worker is injured, each missed day of work represents lost wages. In workers' compensation insurance, indemnity benefits are paid to the employee to help them cover their loss of income. Payments are a portion of the worker's average weekly wage, and take into consideration the extent of the disability.

For assistance, an injured worker, employer, medical provider or insurance carrier may contact the Industrial Accidents Division at (801) 530-6800 or toll free (in Utah) at (800) 530-5090.

In Utah, individuals with no employees and who hire out their services to a hiring employer may be considered “statutory employees.” These individuals are allowed to waive their rights to workers' compensation coverage by obtaining a Workers' Compensation Coverage Waiver (WCCW).

First Report of Injury or Illness -- Forms 122C and 122E. Form 122C is used by the insurance carrier or self-insured employer to report an injury to the injured worker. Form 122E is used by the employer to report an injury to the injured worker and its insurance carrier or the Division, if uninsured.

Compensation shall be 66-2/3% of the employee's average weekly wages at the time of the injury, but not more than a maximum of 66-2/3% of the state average weekly wage at the time of the injury and not less than a minimum of $45.00 per week plus $20.00* for a dependent spouse and $20.00 for each dependent child under ...

Independent contractors are not covered by the Utah Workers' Com- pensation Act, so employees do not need to obtain workers' compen- sation coverage for independent contractors. Independent contrac- tors are not eligible to receive or file workers' compensation claims.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232