Employee Notification Of Denial Of Claim {089}

Official Form 089 EMPLOYEE NOTIFICATION OF DENIAL OF CLAIM Revised 2/2019 160 East 300 South 3rd 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 TO BE COMPLETED BY I NSURANCE CARRIER OR SELF - INSURED EMPLOYER NOTICE TO INJURED WORKER: This form is to notify you, the injured worker, of the denial or partial denial of an industrial accident or occupational disease claim. If you have questions please contact the adjuster assigned to your claim as listed below. If further assistance is required you may then contact the Labor Commission, Division of Industrial Accidents. INJURED WORKER INFOR MATION: Name: P hone: Address: City : State : Zip : SSN : Claim Number: Date of Injury: Employer: Phone: Employer Address: City : State : Zip : Insurance Carrier: Claim Administrator: Adjuster: Phone: Jurisdiction Claim Number (JCN): Adjuster Address: City : State : Zip : Date of Denial : Date Insurance or Self - Insured was Notified : REASON FOR DENIAL (choose one) : Full Denial Partial Denial No Compensable Accident (Not in Course and Scope of Employment) No Causal Relationship No Coverage Substance Use/Abuse Other (Not Elsewhere Classified) Denying Indemnity in Whole, But Not M edical Denying Indemnity in Part, But Not Medical Denying Medical in Whole, But Not Indemnity Denying Medical in Part, But Not Indemnity Denying Indemnity in Whole and Medical in Part Denying Medical in Whole and Indemnity in Part Denying Both Indemnity and Medical in Part Reason Narrative : INSTRUCTIONS FOR INSURANCE CARRIER OR SELF - INSURED EMPLOYER: This form is to be completed by the insurance carrier or self-insured employer on the same day the claim is denied. Mandatory Reporting Requirements: Injured Worker: Carrier must mail Form 089 to the injured worker on the same date the claim is denied (full or partial). Full Denials: Denials on claims with a date of injury of December 31, 2012 and forward must be filed with the Labor Commission using EDI (MTC 04). Claims prior to this date may be filed using EDI or on paper Form 089 and mailed, if preferred. Partial Denials: Partial denials on claims with a date of injury of July 1, 2019 and forward must be filed with the Labor Commission using EDI (MTC PD). Claims prior to this date may be filed using EDI or on paper Form 089 and mailed, if preferred. American LegalNet, Inc. www.FormsWorkFlow.com