Form DWS-ESD19 "Third Party and Insurance Information" - Utah

What Is Form DWS-ESD19?

This is a legal form that was released by the Utah Department of Workforce Services - a government authority operating within Utah. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the Utah Department of Workforce Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DWS-ESD19 by clicking the link below or browse more documents and templates provided by the Utah Department of Workforce Services.

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Download Form DWS-ESD19 "Third Party and Insurance Information" - Utah

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DWS-ESD 19
State of Utah
Rev. 04/2019
Department of Workforce Services
THIRD PARTY AND INSURANCE INFORMATION
Please complete this form if you are applying for, or receiving medical assistance.
Name:
Birth Date:
Case#:
Check the
Insurance Information:
appropriate box
D10819900540101
Does anyone in your household currently have health insurance (including VA Health Care
Yes
System benefits), or:
No
- Have insurance available but not enrolled
- Had insurance in the past 6 months
If yes, please complete the chart below. (Do not list Medicaid, Medicare or CHIP)
Enrolled
Name of insurance company:
Phone #:
Not enrolled,
Address of insurance company:
Group #:
but available
Policyholder name:
Policy #:
Ended,
Policyholder date of birth:
Policyholder SS #:
Date ended:
If insurance is through an employer, list employer name and phone#:
Premium: $
Date due:
How often?
Name of individuals covered (If not listed on the insurance card):
Enrolled
Name of insurance company:
Phone #:
Not enrolled,
Address of insurance company:
Group #:
but available
Policyholder name:
Policy #:
Ended,
Policyholder date of birth:
Policyholder SS #:
Date ended:
If insurance is through an employer, list employer name and phone#:
Premium: $
Date due:
How often?
Name of individuals covered (If not listed on the insurance card):
Major Medical Need Information:
Does someone in your home have a major medical need?*
Yes
No
If yes, who? ____________________________
*Pregnancy is considered a major medical need.
Accident, Assault, or Other Liability: If any household members have been injured in an
Check the type of incident
accident, assault, or someone outside your household is required to pay for medical services,
complete this section.
Automobile
Dog Bite
Name of household member:
Date of Incident:
Assault
Slip/Fall
Who is responsible?
Work-Related
Police department:
Police report #:
Medical Malpractice
Name of attorney:
Phone #:
Other*
*Explain other:
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
DWS-ESD 19
State of Utah
Rev. 04/2019
Department of Workforce Services
THIRD PARTY AND INSURANCE INFORMATION
Please complete this form if you are applying for, or receiving medical assistance.
Name:
Birth Date:
Case#:
Check the
Insurance Information:
appropriate box
D10819900540101
Does anyone in your household currently have health insurance (including VA Health Care
Yes
System benefits), or:
No
- Have insurance available but not enrolled
- Had insurance in the past 6 months
If yes, please complete the chart below. (Do not list Medicaid, Medicare or CHIP)
Enrolled
Name of insurance company:
Phone #:
Not enrolled,
Address of insurance company:
Group #:
but available
Policyholder name:
Policy #:
Ended,
Policyholder date of birth:
Policyholder SS #:
Date ended:
If insurance is through an employer, list employer name and phone#:
Premium: $
Date due:
How often?
Name of individuals covered (If not listed on the insurance card):
Enrolled
Name of insurance company:
Phone #:
Not enrolled,
Address of insurance company:
Group #:
but available
Policyholder name:
Policy #:
Ended,
Policyholder date of birth:
Policyholder SS #:
Date ended:
If insurance is through an employer, list employer name and phone#:
Premium: $
Date due:
How often?
Name of individuals covered (If not listed on the insurance card):
Major Medical Need Information:
Does someone in your home have a major medical need?*
Yes
No
If yes, who? ____________________________
*Pregnancy is considered a major medical need.
Accident, Assault, or Other Liability: If any household members have been injured in an
Check the type of incident
accident, assault, or someone outside your household is required to pay for medical services,
complete this section.
Automobile
Dog Bite
Name of household member:
Date of Incident:
Assault
Slip/Fall
Who is responsible?
Work-Related
Police department:
Police report #:
Medical Malpractice
Name of attorney:
Phone #:
Other*
*Explain other:
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.