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Get Ut 122c 2019-2024

Surance carrier has received initial notice of an industrial accident or occupational disease claim. This form does not indicate acceptance or denial of the claim. If you have questions please contact the claim administrator assigned to your claim as listed below. If further assistance is required you may then contact the Labor Commission, Division of Industrial Accidents. INJURED WORKER INFORMATION: Name: Phone: Address: City: Occupation / Job Title: Employment Status: Wage: Wage Period:.

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