Get Ut 122c 2019-2026

Filling out the UT 122C form accurately is crucial for notifying relevant parties about an injury or illness claim. This guide provides clear, step-by-step instructions to help you complete the form confidently and efficiently.

Follow the steps to fill out the UT 122C form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering the injured worker's information, which includes their name, phone number, address, city, occupation or job title, employment status, wage, and wage period. Select whether full pay was received for the day of injury, noting 'Yes' or 'No' with the corresponding wage frequency.
3. Input the employer's information. Provide the business name, phone number, a contact person at the employer’s office, their phone number, and the complete mailing and physical addresses.
4. Complete the insurance information section. Enter the insurance carrier's name, phone number, mailing address, the claim administrator's details, and policy or self-insured numbers, including the jurisdiction claim number and claim administrator claim number.
5. Fill in the occurrence details, starting with the date and time of the injury. Record the date the employer was notified, the nature of the injury, the body part affected, the cause of the injury, and the last day worked.
6. List important dates such as when the disability began, when the worker returned to work, and if applicable, the date of death. Also, fill out the date the administrator was notified and indicate whether it was a fatality.
7. Detail the address of the occurrence, including the premises, city, state, and zip code. Provide a description of the accident, along with information on any witnesses, if applicable.
8. Review all entered information for accuracy, then proceed to save the changes, download, print, or share the completed form as needed.

Ensure your documents are complete and accurate by filing the UT 122C online today.