Free Utah Application for Lump Sum or Advance Payment (Form 134) - PDF Form Download
Form 134 Application for Lump Sum or Advance Payment is an instrument to request an administrative law judge to pass an order to release the payment in advance under special conditions like an injury at work. Administrative law judge is authorized to pass the order to the Employer and/or Workers’ Compensation Insurance Company under the Section 34A-2-421, U.C.A.
Please read this document carefully before proceeding and provide all particulars truthfully. Your signature on the form is mandatory in acknowledgement of the particulars furnished in the Form 134. Specify the amount requested and the reason for it in detail in the spaces provided for the same as the information furnished is decisive during the passing of the order.
- Complete Form 134, Application for Lump Sum or Advance Payment legibly. Omissions and misinterpretations are not allowed.
- Provide truthful information about the current financial status for judge’s consideration of the request for advance payment.
- Submit duly completed Form 134 to the Office of State of Utah – Labor Commission, Adjudication Division, P. O. Box 146615, Salt Lake City, UT.
- The amount payable by the carrier is subject to discount due to the unaccrued amounts.
Form 134 Application for Lump Sum or Advance Payment seeks input of various personal and financial particulars. Commence by printing the employee name, date of injury, and then print the employer name. You may choose to furnish name of Workers’ Compensation Insurance Company instead of the Employer if applicable.
Proceed to Section 1 and select if you are currently employed and no otherwise. Provide Employer name and monthly earnings in US dollar on the subsequent lines if you select yes. Specify your engagement in a vocational rehabilitation program by selecting yes or no. Provide the name of the rehabilitation counselor on the next line if your response is yes in section 2 of Form 134.
Section 3 requires information about the employment status of your spouse. Record appropriate response and specify the name of the spouse’s employer if your response is yes. Specify the number of children under age 18 in Section 4.
Furnish your monthly liabilities towards living. Provide detailed description of various expense heads and liability in amount towards it. Add the value of all obligations to conclude the total obligation for each month. Use separate sheet if needed. Specify if you or your spouse receive monthly benefits of any sort in Section 6.
Continue by providing the amount in cash or bonds you possess in Section 7. Specify the amount requested for advance payment in Section 8. Provide reasons for making the request in detail in the space reserved in Section 9. Furnishing this information is crucial.
Sign in the space provided and continue by furnishing your street address, city, state, and zip code in the respective spaces. Insert your phone number to complete the Form 134 Application for Lump Sum or Advance Payment. Remainder of the form is reserved for the inputs by the Administrative Law Judge.