Complete the form below:
Petition to Remove Record of Administrative Disciplinary Action and Supporting Declaration
Once you have completed, printed, and signed the form, you must scan it along with any attachments. Please upload it to the Utah Insurance Department using the secure file upload site at https://forms.uid.utah.gov/fileUploads. (If you do not already have an account, you will need to create one.) Select the division “Admin Action Removal” from the dropdown menu. After uploading, an invoice will be generated and sent to your email address.
When you receive the invoice, payment of the $185 fee can be made via debit/credit card, cash, or check. Upon receipt of payment, the Utah Insurance Department has 30 days to remove the requested action/s.
FOR ALL PAYMENT METHODS YOU WILL NEED:
Invoice ID and Payor ID
(Found at the top right-hand corner of the invoice)
Payment by Credit Card: Credit card payments can be made at https://secure.utah.gov/cart/uid_scart/products.html. You will need the credit card number, name, expiration date, and statement billing address. The name of the applicant/petitioner MUST be included when making the payment. You may also make a payment by calling 801-957-9200.
Payment by Check: Make checks payable to: Utah Insurance Department. Send payment to: Utah Insurance Department, 4315 S. 2700 W., Taylorsville, UT 84129.
Payment by E-Check (ACH Debit): For this type of payment, you are providing us the authorization to transfer funds from your checking account to ours. Corporate accounts may have “blocks” that prohibit this type of transaction, so you will need to have your accounting department check with your financial institution to determine if an e-check transaction is allowed. THIS MUST BE DONE BEFORE TRYING TO MAKE A PAYMENT. If you are able to process an e-check, your accounting department will need to provide your financial institution with our originating ID number in order to complete the e-check transaction. Our originating ID is 0000097488. This must be set up prior to your trying to process an e-check transaction. A charge of $25 per transaction will be assessed if an e-check transaction does not process and is returned to us, and the removal of your administrative action will be delayed.
E-CHECK IS THE ONLY ACH TYPE TRANSACTION WE CURRENTLY SUPPORT.
The online form is located at https://insurance.utah.gov/wp-content/uploads/AdminRemoveForm.pdf.
