Free Form 11 - Kentucky

Form 11 Effective 1/31/2005

KENTUCKY DEPARTMENT OF WORKERS' CLAIMS 657 Chamberlin Avenue Frankfort, KY 40601 Workers' Compensation Claim no. __________________

Motion to Substitute Party and Continue Benefits
Come now the undersigned, being all dependents of the deceased Plaintiff, __________________ and hereby move to be substituted as the Plaintiff herein for the purpose of receipt of benefits, and further state as follows: 1. Employee/Plaintiff:_________________________________________SSN:____________________ 2. 3. 4. 5. 6. 7. Date of death (attach copy of certified Death Certificate):___________________________________ Cause of death: ____________________________________________________________________ Date of Award/Settlement and amount: _________________________________________________ Name and address of party paying benefits:______________________________________________ Date of Marriage (attach copy of certified Marriage License): _______________________________ List of dependent(s) (attach copies of certified Birth Certificates):
SOCIAL SECURITY NO. DATE OF BIRTH RELATIONSHIP ADDRESS (city, state, zip code)

NAME

Wherefore, the dependent(s) request that he/she (they) be substituted as the Plaintiff and that said benefits be paid directly to him/her (them). The undersigned hereby states that the foregoing is true and accurate to the best of my knowledge and belief. Respectfully submitted, _______________________________________ (Signature) _______________________________________ Address _______________________________________ Relationship to decedent Subscribed and sworn to before me by ______________________ on this __________ day of ____________________, 20____. ________________________________ Notary Public, Kentucky, State at Large My commission expires: ____________ I certify that copies were mailed this _________ day of ____________, 20______ to: Employer or Attorney for Employer: _________________________________________ Other Parties (if applicable): ___ ____________________________________________

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.