Workers' Compensation Notice for the State of Utah Poster Required

WORKERS’ COMPENSATION NOTICE	 	
Employer:	 	 	
has complied with the provisions of the Workers’ Compensation Act (§34A	-2-101, Utah Code Annotated), the 	
Utah Occupational Disease Act (§34A	-3-101, Utah Code Annotated), and the rules of the Labor Commission by 	
insuring the liability to pay the compensation and other benefits provided by said Acts	 through:	 	
Insurance	 Company:	   	 	
Policy	 Number:	 ______________________________________________________________	 	
Address for the above insurance	 company: 	  	 	
Telephone	 number: 	  	 	
  Check	 here	 if the	 employer	 has	 been	 authorized	 by	 the	 Division	 of Industrial	 Accidents	 to self	-insure	 and	 directly	 pay 	
workers’ compensation	 benefits.	 	
WORKERS’ COMPENSATION	 	
Workers’ Compensation is insurance which pays medical expenses and 	helps offset lost wages for employees with work	- 	
related injuries or illnesses. If you have an on	-the	-job injury or occupational disease, it may pay for: hospital and medical bills, 	
time lost from work, permanent loss of body function, prosthetic devices, 	and burial and dependent benefits in case of death.	 	 	
HOW TO REPORT AN ACCIDENT	 	
1. Report the injury, no matter how slight, immediately to your 
supervisor. You may lose your rights if your injury is not 
reported within 180 days of the injury or wor	k-related	 illness.	 	
2. Ask your employer where you should go for treatment. If	 	
your employer has a first	-aid room or company designated 	
doctor, go there promptly for treatment. If not, go to a 
doctor of your	 choice.	 	
 
3. Tell the doctor 	HOW, WHEN and WHERE 	the 	accident	 	
happened. The doctor will fill out a 	physician’s initial 	report 	
form. A copy of the report is given to you and copies of the 
report are sent to the insurance company and the Labor 
Commission within seven (7) days of your doctor	 visit.	 	
 
4. Your employ	er shall fill out the employer’s first report of 	
injury form. A copy of this report is sent to the insurance	 	
company within seven (7) days of 	the accident. The insurance 	
company will report the injury to the Labor	 Commission.	 	
HOW TO START COMPENSATION	 	
1. Ask	 your employer which insurance company pays	 workers’ 	
compensation benefits for the company.	 	
 
2. Ask your employer to report the accident to the	 insurance 	
company and give you the claim	 number.	 	
 
3. Call the insurance company and ask them to start your 
workers’ 	compensation benefits. The insurance company 	
will require the employer’s report, the physician’s report, 
and may ask you to fill out a request for compensation. 
Cooperate with the adjuster’s investigation of the	 injury.	 	
 
4. Ask your doctor to send medical rep	orts to the insurance 	
company, including the work status	 statement.	 	
REHABILITATION	 	
If you cannot return to work, you may be eligible for a 
rehabilitation program. Contact the insurance company 
listed above or the Utah State Office of Rehabilitation	. 	
 	
FRAUD STATEMENT: “Any person who knowingly presents false or fraudulent underwriting 	
information, files or causes to be filed a false or fraudulent claim for disability compensation or medical 	
benefits,	 or submits	 a false	 or fraudu	lent	 report	 or billing	 for	 health	 care	 fees	 or other	 professional	 services	 is 	
guilty of a crime and may be subject to fines and confinement in state	 prison.”	 	
 
 	
 	
 	
160 East 300 South 3	rd Floor P.O. Box 146610 Salt Lake City, Utah 84114	-6610	 	
Office: (801)	-530	-6800 Fax: (801)	-530	-6804 Toll Free: (800)	-530	-5090 	www.laborcommission.utah.gov	 	
 
If you want copy of an 	Employee's Guide to Workers' Compensation 	booklet or have questions, contact the 	
Labor Commission or go to the webpage at 	www.laborcommission.utah.gov	. 	
Note:	 This	 notice	 must	 be	 posted	 and	 kept	 continuously	 in public	 and	 conspicuous	 places	 in the	 office,	 shop	 or 	
place	 of	 business	 of	 the	 employer	 as per	 §34A	-2-204	 and	 §34A	-2-104.5,	 Utah	 Code	 Annotated.	 	
 	
Rev 10/2019