Form 130 - Insurance Company'S And Self Insurer'S Final Report Of Injury And Statement Of Total Losses - Labor Commission, Utah

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Insurance Company’s and Self Insurer’s Final Report

Form 130

of Injury and Statement of Total Losses

PLEASE PRINT OR TYPE

INSTRUCTIONS: This final report MUST BE FILED as soon as possible, but not later than thirty

(30) days after final payments are made in all workers' compensation cases. List ALL medical

payments made, even if reimbursed by the Employers' Reinsurance Fund. This form is to be filed

when an Order is entered.

..................................................................................................................................................................................

Employer's Name: ____________________________________________________________________

Employer's Address __________________________________________ Zip: _______________

Employee's Name: _______________________________Date of Injury: _________________________

Employee's Social Security Number: ________________________________

When was employee physically able to return to work? ___________________________

Light Duty/Part-Time: ________________________________ Full duty____________________________

(Indicate Period of Time)

Actual number of days injured was absent from work: _______________________________

PAYMENTS

Temporary Total for: _________

weeks at $ _______

for a total of $__________