Application For Hearing For Termination Or Reduction Of Compensation {402}

Form 402 3/1/12 StateofUtahLaborCommission AdjudicationDivision 160East300South,3rdFloor,P.O.Box146615 SaltLakeCity,Utah841146615 (801)5306800 casefiling@utah.gov Note:PLEASETYPEORPRINTINBLACKINK Employer(Petitioner) Employer'sMailingAddress City,StateandZipCode Employer'sEMailAddress Petitioner'sWorkers'CompInsuranceCarrier InsuranceCarrier'sMailingAddress City,StateandZipCode InsuranceCarrier'sEMailAddress vs. Respondent(Employee) Respondent'sMailingAddress City,StateandZipCode Respondent'sPhoneNumber APPLICATIONFORHEARING FORTERMINATIONORREDUCTIONOF COMPENSATION (NOTE:Includeallsupportingdocumentationwhen thisformisfiledwiththeLaborCommissionorthe ApplicationforHearingmaybereturned) SupportingDocumentationRequiredforthis Application: ProofofService NoticeofRequestforTerminationorReductionof Compensation PersonswithKnowledgeList PETITIONERALLEGESANDREQUESTSRESOLUTIONCONCERNINGTHEFOLLOWINGUNDERTITLE 34A: 1. 2. 3. Dateofindustrialinjury:Month __________ Date________Year________ . Petitioner requests respondent's compensation be (check one) _______terminated or ______reducedby$_________perweek. Thebasisforthisreduction/terminationis: _____________ (listspecificcitationto§34A2410.5 relieduponforthisrequest).Thepetitionerallegesthefollowinginsupportofthisclaim: American LegalNet, Inc. www.FormsWorkFlow.com Form 402 3/1/12 Petitionerverifiesthattheaboveinformationistrueandcorrecttothebestofpetitioner's informationandbelief. PrintedNameofAttorneyforPetitioner/Respondent SignatureofPetitioner StateBar# SignatureofAttorneyforPetitioner/Respondent Petitioner'sTelephoneNumber Date MailingAddressforAttorneyforPetitioner/Respondent City/State/ZipCode TelephoneNumber FAX EMailAddress American LegalNet, Inc. www.FormsWorkFlow.com