Follow the steps to successfully complete the UT Form 110

1. Press the ‘Get Form’ button to access the UT Form 110 online and open it in your preferred editor.
2. Begin by entering the worker's name in the appropriate field. Ensure accuracy as this information is critical for identification.
3. Provide the worker's address, including street, city, state, and zip code. This helps in ensuring the correct correspondence.
4. Supply the worker's phone number, allowing for easy communication if further information is needed.
5. Fill in the injury date, which should reflect the date when the accident or injury occurred.
6. Enter the employer's name to clarify which organization the form pertains to.
7. Indicate the actual number of lost workdays as a result of the injury. This is important for understanding the impact of the injury.
8. Provide the worker's Social Security number (SS#) for identification purposes.
9. Select whether the worker has been released to regular duty or light duty by marking the appropriate option.
10. Include the relevant dates for the release to regular and light duty, ensuring they are accurate.
11. If applicable, document any permanent impairments in the designated section.
12. State the anticipated date of release to regular duty, providing a clear timeframe for the worker’s return.
13. Fill in the name of the person submitting the form, typically the adjuster or relevant authorized individual.
14. Input the name of the insurance carrier involved in the worker’s claim.
15. Provide the phone number of the insurance carrier for any follow-up queries.
16. Complete the form by entering the date it is submitted. Ensure all fields are correctly filled out.
17. Finally, save your changes, and then download, print, or share the completed UT Form 110 as required.

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