Form 141 - Initial Statement Of Insurance Carrier Or Self-Insurer With Respect To Payment Of Benefits
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INITIAL STATEMENT OF INSURANCE CARRIER OR SELF-INSURER
Form 141
WITH RESPECT TO PAYMENT OF BENEFITS
PLEASE PRINT OR TYPE
Original
Amended
Reason(s) for Amendment ________________________________________
Total Cumulative Lost Work Days Due to this Injury__________________________________________
Employee _________________________
Date Carrier Notified of Lost Time ______________________
Survivor _________________________
Employee Phone _____________________________________
Address _________________________
Social Security Number _______________________________
_________________________
Please list part of body injured __________________________
Claim Number __________________
Date of Injury _____________________________________
Claim is for a FATALITY
Employer __________________________________________
(List Fatality Dependent(s) as an Addendum)
Claim is for Injury
Employer __________________________________________
Claim is for Occupational Disease
Address ____________________________________________
City, State, ZIP
______________________________________
COMPUTATION OF BENEFIT RATE
Basic Rate of Pay (Specify whether per hr/day/week/month) ________________ $ _______________
Basic Benefit Rate (2/3 of Gross Avg. Weekly Wage
not to exceed Maximum)
= $ _______________
$5.00 dependency allowance for spouse
and
dependent children
$_______________
Amount of weekly benefit (Basic + Dep. Allowance)
= $ _______________
The Maximum =100% State Average Weekly Wage: Dependents' benefits of $5.00 for spouse and $5.00 for each
dependent minor child under 18 (up to 4) is added to reach maximum, but at no time can the weekly benefits exceed
the maximum, or be less than the minimum of $45.00 per week. The maximum up to July 1, 2007 to June 30, 2008
-- $665.00, July 1, 2009 to June 30, 2010 -- $720.00, July 1, 2010 to June 30, 2011 -- $732.00, July 1, 2011 to
June 30, 2012 -- $747.00. The first 3 days are not compensable unless 15 days or more are missed.
First check for
weeks
days from
to
in the amount of $________
was mailed on ___________________.
Insurance Carrier _______________________________ Phone _______________________________
Adjustor ____________________________ Adjustor’s Signature ______________________________
(Type or Print)
Adjustor’s Address _____________________________________________________________________
(Street / PO Box)
(Phone Number)
(City, State, Zip)
“Statement of Insurance Carrier or Self Insured with Respect to Payment of Benefits – Form 141” - This form is
used for reporting the initial benefits paid to an injured employee. This form must be filed with or mailed to the
Labor Commission on the same date the first payment of compensation is mailed to the employee. A copy of this
form must accompany the first payment.
NOTICE TO EMPLOYEE Travel Reimbursement for Medical Care: You may be eligible for reimbursement for
travel to and from medical care which has been authorized by the insurance carrier (per rule R612-2-20). You will
need to contact your insurance adjuster.
Official Form 141
Revised 7/11
State of Utah ● Labor Commission ● Division of Industrial Accidents
160 East 300 South● P.O. Box 146610 ● Salt Lake City, UT 84114-6610 ● Telephone: (801) 530-6800
Fax: (801) 530-6804 ● Toll Free: (800) 530-5090 ●
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