Get UT Form 110 2016-2021
work. The form must be submitted to the Labor Commission and to the injured worker within five (5) days of the release date. General Information Worker Name Address Phone Number Injury Date Employer Actual # of Lost Work Days SS# Released to Regular Duty Released to Light Duty Date Date Permanent Impairments, if any: Permanent Impairments, if any: Anticipated Date of Release to Regular Duty: Name of Person Submitting Form Carrier Name Phone Number Official Form 110 Date Submitted Re.
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