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Forms
CLAIM FORMS
File a Claim Online
Direct Deposit Form
Direct Deposit Form (español)
Letter for Treating Physician
Physician's Return to Work Recommendations
Restorative Services Authorization/Denial - Form 221a - Spine
Restorative Services Authorization/Denial - Form 221b - Upper Extremity
Restorative Services Authorization/Denial - Form 221c - Lower Extremity
UNDERWRITING FORMS
Agriculture Employees
Application for Insurance
Application for Insurance (español)
Authorization Agreement for Automatic Payment
Cancellation Request
Termination Notice for Automatic Payments
General Business Supplemental Questionnaire
General Business Supplemental Questionnaire (español)
Dairy Supplemental Questionnaire
Contractor Executive Supervisor Questionnaire
Policy Review Form
Policy Review Form (español)
Aviation Questionnaire
Trucking Questionnaire
Trucking Questionnaire (español)
Waiver of Subrogation
Waiver of Subrogation (español)
Arizona Alcohol-and Drug-Free Workplace Premium Credit
Idaho Alcohol-and Drug-Free Workplace Premium Credit
UTAH ASSOCIATION AGREEMENTS
ABC Participation Agreement
AGC Participation Agreement
HBA Participation Agreement
UMA Participation Agreement
URA Participation Agreement
URCA Participation Agreement
UTA Participation Agreement
Pre-Approved Safety Courses for Association Credit
UTAH LABOR COMMISSION FORMS