Form 103 Revised 6/05
KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Application for Resolution of Hearing Loss Claim Claim No. _____________________
Plaintiff _________________________________ Social Security Number _________________________________ Birth Date _________________________________ Street Address _________________________________ City/State/Zip Code _________________________________ County _________________________________ Phone Number
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: ___________________________________ __________________________________
I. Nature of Injury 1. Plaintiff states that on the _______ day of ________ 20____, he/she sustained or became disabled due to occupational hearing loss arising out of and in the course of his/her employment. Plaintiff became aware of this condition on:__________________________________________________________
State the date and means by which plaintiff gave notice of the injury to employer. _____________________________________________________________________________________________ _____________________________________________________________________________________________ Place of last exposure ___________________________________________________________________________ (city) (county) (state) Nature of the work in which the plaintiff was engaged at the time of exposure_______________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ How did exposure to the disease occur? (Describe in detail) ____________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________
II. Personal Data 7. Name and address of last school attended: ____________________________________________________________ ______________________________________________________________________________________________ Highest grade completed in school: ____________________ GED awarded _____yes ______no
10. Professional or vocational degrees, certificates, or licenses: ______________________________________________ ______________________________________________________________________________________________ 11. Dependents: Name Social Security Number Relationship
12. Has plaintiff previously filed for or received workers' compensation benefits? _____yes _____no; If yes, give dates, nature of injury or disease and any award of benefits received: ____________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ III. Employment Data 13. Type of work performed at date of occupational disease: _______________________________________________ 14. Describe the physical requirements of plaintiff's customary job: __________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 15. Weekly wage at date of occupational disease: _________________. Attach copy of any proof of wages, such as paycheck stub, W-2, etc. 16. Has plaintiff returned to work? _____yes _____no; if yes, name and address of current employer and description of job currently being performed: ____________________________________________________________________ _____________________________________________________________________________________________ 17. Is plaintiff exposed to occupational noise in his/her current job? _____yes _____no
18. 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.
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