Form 5020 West Valley City Utah 2025

Form 5020 West Valley City Utah: What You Should Know

Part 11 Work Related Injury and/or Illness — West Valley City, UT Worker's Compensation Administrative Case Management System (ACCM) Employee Questionnaire (ESQ) Form. A-100. A-105 is not accepted unless a worker has completed the ESS for Employee/Permanent Disability under the West Valley City Employer's Compensation Plan. If a worker has a disability/illness that must be reported, they will be asked to make a claim. The claim is made on this form, and also on a paper form. (See instructions below for the request) Work Related Injury and/or Illness. The Accident Compensation Program (ACC) requires that all workers who do not meet the definitions as determined in Chapter 11 of the California Code of Regulations, Title 49, Division 3, Part 103 are subject to reporting. If you are contacted regarding work-related injuries and/or illnesses, take the Accident Compensation Claim Form to the West Valley City Employment Section and complete the entire claim. Failure to complete the Accident Compensation Claim Form will result in denial of benefits. Claim Forms are in this publication, along with the Accident Compensation Claim Form Guide for Workers' Compensation Program and Forms and Forms of the West Valley City Human Resources Department. The Claim Form Guide for Human Resources and Information Service is available at the Workplace Services office in Building 535, South 300 East. (See instructions below for the request) Work Related Injury and/or Illness (includes work related injuries, accidents and illnesses.) The Accident Compensation program does not require a claim form. If you are contacted regarding work-related injuries and/or illnesses, take the Accident Compensation Claim Form to the West Valley City Employment Section and complete the entire claim. Failure to complete the Accident Compensation Claim Form will result in denial of benefits. If a worker is subject to reporting, they will be asked to make a report to Accident Compensation via phone or in writing. For your convenience, there is a completed Form to report an injury or illness. The claim form must be completed in color. Send the completed claim form to the Accident Compensation Program. The information should be on an official white or brown card. For assistance call. The form and instructions can be picked up at the West Valley City Employment Office, 400 South 700 West (EQ).

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