Application For Resolution Of A Claim Hearing Loss {103}

APPLICATION FOR RESOLUTION OF A CLAIM – HEARING LOSS. This Kentucky Department of Workers’ Claims form is used to file and resolve a workers’ compensation claim specifically related to occupational hearing loss. It requires information about the plaintiff, employer, insurance carrier, and any additional parties. Claimants must provide details on the nature of the hearing loss, last exposure or accident, notice to the employer, medical reports, type of work performed, and whether an interpreter is needed. The form also collects prior workers’ compensation history, concurrent employment details, and current employment information. Education background, vocational training, and potential safety rule violations under KRS 342.165 may also be reported. A signed declaration affirms the accuracy of the information and warns against fraudulent claims. www.FormsWorkflow.com