Free Notice of Claim De nial or Acce ptance - Kentucky

Notice of Claim Denial or Acceptance Form 111- Injury and Hearing Loss Adopted 1/1/97

Filed:

COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS CLAIMS Before Arbitrator Claim Number NOTICE OF CLAIM DENIAL OR ACCEPTANCE
Do Not Write In This Space

Plaintiff/Employee vs. Defendant/Employer , as insured by Comes the defendant, response to the Application for Resolution of Claim, states as follows: 1. , and in

This claim is accepted as compensable in its entirety. A settlement agreement will be filed. (Note: if claim is accepted, do not complete paragraphs 2 - 7). This claim is accepted as compensable, but there is a dispute concerning the amount of compensation owed to the plaintiff. This claim is denied for the following reasons: (a) Plaintiff was not employed by defendant on the date of alleged injury. Explain: The alleged injury did not arise out of and in the course of employment. Explain: The plaintiff did not give due and timely notice to employer of the injury. Explain: The claim is barred by limitations. Explain:

2.

3.

(b)

(c)

(d)

Other reason for denial. Explain: 4. The plaintiff's average weekly wage at the time of the alleged injury was $ . Completed AWW-1 to support this calculation is attached, if amount is different from plaintiff's application for resolution. The following witnesses may present testimony relevant to denial of this claim. 1. 2. 3. 4.

5.

6.

The following are admitted by the employer: Yes No Plaintiff's injury was covered under the Workers Compensation Act. The injury occurred or became disabling on ____________, 199___
Date

Plaintiff gave due and timely notice of the injury. Plaintiff has returned to work for this employer and is earning $_______ per week. Temporary total disability income benefits were paid as the result of the injury. All known medical expenses have been paid as the result of the injury. 7. Describe in detail the physical requirements of plaintiff's job at the time of the alleged injury. If an official job description exists, a copy must be attached. The following persons have gathered information for completion of this form. For the employer:
Name Title

8.

Address:

Street

City ( ) Telephone Number

State

Zip Code

For the insurance carrier:

Name

Title

Address:

Street

City ( ) Telephone Number

State

Zip Code

Being duly sworn, the undersigned states that the statements in this form are true and correct to the best day of , 199 . of my knowledge and belief. This the
Signature Address Phone Number Title

Subscribed and sworn to before me this My commission expires: County: Prepared and submitted by: Representative/Title

day of

, 199

Notary Public

Address

Phone Number