Request To Waive Or Postpone Reemployment Referral {215}

Print Form FORM 215-Insurer/Employer Request to Waive/Postpone Reemployment Referral INSTRUCTIONS: Insurance carriers and employers may submit this form to request waiver or postponement of their obligation under Section 34A-8a-302 of the Utah Injured Worker Reemployment Act to refer a disabled injured worker for rehabilitation or reemployment services. This form must be submitted to the Division of Industrial Accidents and also mailed to the injured worker within 10 day after submission of Form 206 ­ Insurer/Employer Initial Reemployment Report for Injured Worker. The Division will note its approval or disapproval on the bottom portion of this form and then mail a copy to the injured worker and to the WC insurance carrier or employer. The Labor Commission rules and forms related to the Utah Injured Worker Reemployment Act can be found on the Division of Industrial Accidents' website at http://laborcommission.utah.gov/IndustrialAccidents/index.html PLEASE PRINT OR TYPE Date FORM 215 submitted: _____/_____/_____ Request for: waiver or Reason for waiver or postponement: The injured worker is not medically stable. (Please use MM/DD/YYYY for all dates) (MM/DD/YYYY) (MM/DD/YYYY) postponement until _____/_____/_____ The injured worker's physical capacity has not been determined. Please enter date by which you expect to obtain determination of physical capacity: Date: _____/_____/_____ (MM/DD/YYYY) Liability for the injured worker's claim is under review. (Note: if waiver or postponement is requested for this reason, explain why it is not possible to refer the injured worker for the free services offered by the Utah State Office of Rehabilitation.) Other reason(s) to request waiver or postponement of rehabilitation or reemployment referral: Explanation: _________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Insurer or Employer's Name and Contact Information: Contact's Name: ______________________________ Contact's Signature: ___________________________ Mailing Address:_______________________________ _______________________________________ Telephone: (_____)_____ - ______ Email: ________________________________ City: ________________ State: ____ Zip:______ Injured Worker's Full Name and Contact Information: _________________________________________ Mailing Address:_______________________________ City: ________________ State: ____ Zip:______ Date of Birth: _____/_____/_____ (MM/DD/YYYY) Social Security #: XXX ­ XX ­ _____ (four digits only) Date of Injury: _____/_____/_____ (MM/DD/YYYY) Telephone: ( _____)______ - ______ SEND COMPLETED FORM to: Utah Industrial Accidents Division (mailing address shown below) ----------------------------------------------------------------------------------------------------------------------------------Date: _____/_____/_____ (MM/DD/YYYY) Approved NOT approved Division of Industrial Accidents ­ Utah Labor Commission Name: _____________________________________________ Signature: __________________________________________ Title: ___________________ Form 215 Adopted October 14, 2009 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 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com