- Contact a preferred urgent care facility by telephone prior to sending the injured worker.
- Inform the urgent care that you have an injured worker coming and that Benchmark Administrators is the claims administrator.
- Advise the urgent care you require a mandatory drug test per the insurance company.
- If a worker is seriously injured and needs immediate care or is transported by ambulance, the
employer should have a co-worker or supervisor go with the injured worker to assist the injured
worker with any insurance related information that the medical provider may require.
- If possible, the injured worker must return to your office or job site after seeing the doctor and give you the doctor’s signed return to work slip or disability slip.
- It is necessary that the employer fill out the required Form 122 and notify us immediately. Please forward the return to work/disability slip from the doctor to Benchmark Administrators as soon as possible.

Utah
When an employee is injured on the job, proceed with the following:
Required State Forms
Provo - Form 122Additional Forms
Medical Provider Options:
FirstMed
441 S. Redwood Road
Salt Lake City, UT 84104
801-973-2588
Intermountain WorkMed
1685 W. 2200 S.
Salt Lake City, UT 84119
801-972-8850
St. Mark’s Hospital
1160 E 3900 S #2000
Salt Lake City, UT 84124
801-266-3418
U of U Hospital
50 Medical Drive
Salt Lake City, UT 84132
801-581-2121
Timpanogas Regional Hospital
750 W 800 N
Orem, UT 84057
801-714-6000
Mountain View Hospital
1000 E 100 N
Payson, UT 84651
801-465-7000
Please send the Form 122 and the medical slip to:
Benchmark Administrators
P.O. Box 46350
Las Vegas, NV 89114
Telephone: (866) 221-3110
Toll Free: (800) 362-5198
Fax: (801) 623-6035
24-HOUR CLAIM REPORTING HOTLINE: 1-866-337-0891
Customer Service Representatives are on staff 24 hours per day to assist you with reporting a
claim. Please have the injured worker’s information available as well as the accident
description.