Utah Counties Insurance Pool
 
Online Forms

First Report of Injury or Illness (Form 122)

Authorization for Medical or Hospital Treatment (20KB .doc file)

Release of Medical Information (43KB .doc file)

Transitional Duty Job Offer Letter (21KB .doc file)

Employee's Written Statement (20KB .doc file)

Witness Written Statement (22KB .doc file)

Travel Reimbursement (26KB .doc file)

OSHA Form 300 (153KB .xls file)

Fire and Safety Inspection Checklist (64KB .xsl file)

EMS Bloodborne Form 350 (104KB .pdf file)

Job Safety Analysis Form(176KB .doc file)

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