Application For Resolution Of A Claim Occupational Disease {102D}

APPLICATION FOR RESOLUTION OF A CLAIM – OCCUPATIONAL DISEASE. This Kentucky Department of Workers’ Claims form (rev. February 2020) is used to file and resolve workers’ compensation claims arising from occupational diseases. Claimants must provide identifying information for themselves, their employer, and insurance carrier, along with medical and employment history. The form requires the date and location of last exposure, the nature of the occupational disease, notification details to the employer, physician information, and the type of work performed at exposure. It also addresses dependents in the event of death (Form F required), prior claims, retraining benefits, concurrent employment, and current work status. Special questions apply for coal industry workers. Education and vocational background must be listed, and safety rule violation claims under KRS 342.165 require an accompanying Form SVC. The form concludes with a fraud warning and claimant declaration. www.FormsWorkflow.com