Petition For Reimbursement From The Employers Reinsurance Fund

THE LABOR COMMISSION OF UTAH * __________________Applicant, * * * Social Security Number: _____________ * * vs. * * __________________Defendants. * * * ***************************** PETITION FOR REIMBURSEMENT FROM THE EMPLOYERS' REINSURANCE FUND COMES NOW _____________________________________________________________________ employer/carrier in the above-entitled matter and represents to the Labor Commission that they have paid $_______________________ as temporary total disability compensation for the period of ________________ to ___________________, and/or $____________________________ as medical expenses for a period of ___________________________ to ________________________ on behalf of the Applicant for an industrial accident sustained on _____________________. The attached medical report/order indicates the Applicant has a permanent partial impairment of _________% due to the industrial accident, and _________% due to preexisting conditions which, pursuant to Section 34A-2-703, Utah Code Annotated, is the responsibility of the Employers' Reinsurance Fund, and accordingly, the above named employer/carrier hereby requests reimbursement for ________% / $__________ of the foregoing amounts from the Employers' Reinsurance Fund. ATTACHED IS VERIFICATION OF AMOUNTS EXPENDED ON THE ABOVE (Calculation verification tapes must be attached) Please remit payment to: ____________________________________________________________________ ________________________________ Complete Street Address or P O Box ______________________ City ___________ _______________ State Zip Code By ________________________________________ (Signed) ___________________________________________ Company's Tax Identification Number ________________________________ Phone Number SUBSCRIBED AND SWORN to before me this ________ day of __________________, 2_________ Approved/Amount $ ___________________________ Disapproved/Amount $_________________________ Reason(s)__________________________________ ERF Reimbursement Petition 8/2008 American LegalNet, Inc. www.FormsWorkFlow.com ______________________________________ NOTARY PUBLIC