Free Form 101 - Kentucky

Form 101 Revised 6/05

KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Application for Resolution of Injury Claim Claim No. _____________________
vs.

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Plaintiff _________________________________ Social Security Number _________________________________ Birth Date _________________________________ Street Address _________________________________ City/State/Zip Code _________________________________ County _________________________________ Phone Number

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Defedant/Employer ___________________________________ Street Address ___________________________________ City/State/Zip Code ___________________________________ Insurance Carrier ___________________________________ Street Address ___________________________________ City/State/Zip Code ___________________________________ Other Defendant ___________________________________ Street Address ___________________________________ City/State/Zip Code Reason for Joinder: ___________________________________ ___________________________________ ___________________________________ Other Defendant ___________________________________ Street Address ___________________________________ City/State/Zip Code Reason for Joinder: ___________________________________ __________________________________

Filed:

I. Nature of Injury 1. Plaintiff states that on the _______ day of ________ 20____, he/she was injured within the scope and course of employment with defendant employer at ___________________________________________________________ (City/County/State)

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Describe how the injury occurred: __________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Body part injured:________________________________________________________________________________ State the date and means by which the plaintiff gave notice of injury to the employer: ______________________________________________________________________________________________ ______________________________________________________________________________________________ Describe medical treatment, if any: __________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Name and address of physician whose report is attached: _________________________________________________ _______________________________________________________________________________________________ II. Personal Data

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Name and address of last school attended: ____________________________________________________________ ______________________________________________________________________________________________ Highest grade completed in school: ____________________ GED awarded _____yes ______no

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10. Professional or vocational degrees, certificates, or licenses: ______________________________________________ ______________________________________________________________________________________________ 11. Dependents: Name Date of Birth Social Security Number Relationship

12. Have you previously filed for or received workers' compensation benefits? _____yes _____no If yes, give Department of Workers' Claims file number(s), dates and nature of injury or disease and any award of benefits received: ______________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ III. Employment Data 13. Is plaintiff currently working? _____yes _____no 14. Type of work performed at date of injury: ___________________________________________________________ _____________________________________________________________________________________________ 15. Describe the physical requirements of job performed at date of injury: _____________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 16. Weekly wage at date of injury: _________________. Attach copy of any proof of wages, such as paycheck stub, W2, etc.

17. Weekly wage currently earned: ________________. Attach copy of any proof of current wages. 18. Name and address of current employer and description of job currently being performed: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 19. Are you alleging a violation of a safety rule/regulation pursuant to KRS 342.165? _____yes _____no Notice: Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Plaintiff herein being duly sworn, states that the statements in this application and in Form 104, 105, and 106 are true. This the _______ day of _________________ 20____. ________________________________________ Plaintiff's Signature Subscribed and sworn to before me this _____ day of _______________ 20____. _________________________________________ Notary Public My Commission expires:____________ County: _________________ Prepared and submitted by: ___________________________________ Signature/Representative for Plaintiff ___________________________________ Title ___________________________________ Street Address ___________________________________ City/State/Zip ___________________________________ Telephone Number

Instructions for Completion of Forms 101, 102 and 103 Form 101 ­ Application for Resolution of Injury Claim 1. All sections of this form must be completed, and must be accompanied by the following: a. Form 104 (Plaintiff's Employment History) b. Form 105 (Plaintiff's Chronological Medical History) c. Form 106 (Medical Waiver and Consent) d. Medical report describing and supporting the injury which is the basis of the claim. e. Proof of Wages, including W-2's, paycheck stubs, etc. All information must be typewritten. File the original of this form and sufficient copies for all named defendants with the Department of Workers' Claims, Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky, 40601. If you have no telephone number, please list a number at which you may be contacted. If you have questions, call 1-800-554-8601. Form 102 - Application for Resolution of Occupational Disease Claim, and Form 103 ­ Application for Resolution of Hearing Loss Claim 1. All sections of this form must be completed, and must be accompanied by the following: a. Form 104 (Plaintiff's Employment History) b. Form 105 (Plaintiff's Chronological Medical History) c. Form 106 (Medical Waiver and Consent) d. Medical report supporting the occupational disease e. Proof of Wages, including W-2's, paycheck stubs, etc. f. Social Security earnings record release form. This form may be filed in combination with an Application for Resolution of Injury Claim (Form 101) if both benefits are sought. Information provided should be current through the date application is signed by plaintiff. All information must be typewritten. File the original of this form and sufficient copies for all named defendants with the Department of Workers' Claims , Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky, 40601. If you have questions, call 1-800-554-8601.

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Note: Special attention should be given to stating the correct name and address of the employer and insurance carrier. Otherwise, claim processing may be delayed.
Revised January 25, 2005