Get Ut 044 2019-2025

The UT 044 form is essential for employees who wish to notify their employer about leaving their locality or state, as well as changing their medical provider. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to accurately fill out the UT 044 form online:

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the name of your employer in the designated field.
3. Provide the date of your injury, as noted in the appropriate section.
4. Fill in the street address of your employer, ensuring all details are correct.
5. List the insurance carrier's information in the corresponding field.
6. Complete the city, state, and zip code of your employer's location.
7. Input your employer’s area code and telephone number.
8. Print your name clearly in the ‘Name of Employee’ section.
9. Enter your current Utah street address in the respective space.
10. Detail your new address, including the city, state, and zip code.
11. Specify your phone number in Utah.
12. Indicate whether you left or intend to leave the state by circling the appropriate option, along with the departure date.
13. Mention the name of your last physician in Utah.
14. State whether you have or have not had a current examination, circling your choice.
15. Enter the full name and title of your new physician.
16. Provide the complete address, phone number, and area code of your new physician.
17. Check the box to confirm that the Attending Physician’s Statement (Form 043) is attached to your request.
18. Sign the form in the designated area to acknowledge your submission.
19. Indicate who should acknowledge receipt of the form and list recipients for copies.
20. Finally, mail the completed form to the Utah Labor Commission – Industrial Accidents Division.

Complete your forms online to ensure a smooth submission process.