Utah Required Postings and Forms
Please print and post the following notices, both in English and Spanish, in a conspicuous location frequented by employees, such as the break room, lunch room or time clock. If you have multiple business locations, be sure to post the notices at each location.
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- Form 122 Workers’ Compensation Employer’s First Report Injury or Occupational Disease. You need to complete and return this form to EMPLOYERS within seven days of your knowledge of an employee injury or occupational disease that results in medical treatment by a physician, loss of consciousness, loss of work, restriction of work, or transfer to another job. Please provide a copy to the employee and keep a copy for your records. Work-related serious injuries (amputation, fractures of major bones both simple and compound-and hospitalization for medical treatment) and fatalities must be reported within eight hours.
- Wage Statement. This form enables us to calculate the correct compensation that may be owed to your injured employee. Please complete the form and submit it to EMPLOYERS within seven days after your knowledge of any accident that has caused your employee to be disabled for more than three calendar days.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or occupational disease to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 14791, Lexington, KY 40512-4791. You should also keep a copy on file for your records.
More Utah Workers’ Comp Resources
- Off-Site Transitional Duty Program – Helping Your Injured Employees Get Back to Work. A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.