West Jordan Utah Form 8689 2024-2025

West Jordan Utah Form 8689: What You Should Know

Complete a form, form SS-10, Employer Provided Report, that states the injured worker has been placed in the injured worker group, with your first and last name. Attach this form to the injured worker's medical claim form. When sending your injured worker's medical insurance claim on this form be sure to include your first and last name as well as that of the injured worker. Provide the injured worker with a medical insurance claim form with your employer's name, full name, address, business address, and phone number. You do not have to send a medical claim form from your insurance provider to the insured worker; your insurance company will mail this form to the injured worker. If there are no injured workers in your company, complete the form, Form 8850-S (Employee Self-Insurance Information Form), that states the injured worker was placed in the injured worker group and gives your name, business address and phone number. The employer reports this information on the injured worker's medical and claims forms. If any employee dies, file a claim on Form SSA 09-1057, or on Form 8850-S (Employee Self-Insurance Information Form), that states the injured worker was placed in the injured worker group, with your first and last name. Include a copy of Form 6829 for the death. Report your death on the next business day after the death and submit the application and payment to the insurance agent. For more information see the form SS-10, Employer Provided Report, and also read “Utah Workers Comp,” by David Rama, Benchmark Health Services, June 2002, pp. 8–13. If there is a claim to be assessed against the employer, the employer must: Attach form SS-10, Employer Provided Report, to the injured worker's medical claim form Attach the injured worker's medical insurance claim form to the application and/or payment Provide the injured worker with a second medical claim form and/or payment form Report the injury claim to the insurance company. All injured workers, regardless of what their employer is, become entitled to receive an employer provided report. All injured workers with injuries for which a claim of payment (from you) is warranted, who are still employed by the same employer after 10 weeks have passed since their injury, become entitled to a new assessment of payment for the same injury.

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