Kentucky > Workers Comp
Application For Resolution Of Coal Workers Pneumoconiosis Claim 102-CWP - Kentucky
| Application For Resolution Of Coal Workers Pneumoconiosis Claim Form. This is a Kentucky form and can be used in Workers Comp . |
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Form 102-CWP Adopted 7/02 KENTUCKY DEPARTMENT OF WORKERS CLAIMS Application for Resolution of Coal Workers Pneumoconiosis Claim Claim No. ___________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Plaintiff Defendant/Employer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Security Number Street Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Birth Date City/State/Zip Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Street Address Insurance Carrier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City/State/Zip Code Street Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . County City/State/Zip Code . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Defendant Filed: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Street Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City/State/Zip Code Reason for Joinder: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Defendant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Street Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City/State/Zip Code Reason for Joinder: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I. Nature of Occupational Disease 1. Plaintiff states that on the ................................ day of .................................., 20.........., (day) (month) (year) he/she became affected by coal workers pneumoniosis arising out of and in the course of oc his/or her employment. <<<<<<<<<********>>>>>>>>>>>>> 22. State the date and means by which plaintiff gave notice of the injury to employer. ________________________________________________________________________ 3. Place of last exposure: (city) (county) (state) 4. Nature of the work in which the plaintiff was engaged at the time of exposure ________________________________________________________________________ 5. How did exposure to the disease occur? (Describe in detail) ________________________________________________________________________ II. Personal Data 6. Name and address of last school attended: ____________________________________ 7. Highest grade completed in school: __________________________________________ 8. GED awarded: _____ yes _____no 9. Professional or vocational degrees, certificates, or licenses: ________________________ ________________________________________________________________________ 10. Dependents: Name Social Security Number Relationship 11. Has plaintiff previously filed a claim for Kentucky coal workers pneumoconiosis benefits (including retraining incentive benefits)? ___yes ___no If yes, give the date and defendant in previous claim: ___________________________ _______________________________________________________________________ III. Employment Data 12. Weekly wage at date of last exposure: _____________________________________ Attached copy of any proof wages, such as paycheck stub, W-2, etc. 13. Is plaintiff currently employed? ___ yes ___no Name and address of current employer : _______________________________________ ________________________________________________________________________ 14. Is plaintiff still working in an environment where he/she is exposed to the hazards of the disease ? ____ yes ____ no 15. Number of years of exposure to hazards of occupational disease 16. Has plaintiff been exposed to the disease while working for more than one employer? ____ yes ____ no 17. Weekly wage currently earned: _________ Attach copy of any proof of current wages. <<<<<<<<<********>>>>>>>>>>>>> 3 IV. Medical Data 18. List name and address of "B" reader whose report is attached to this Form. File original x- ray read by this "B" reader with this form. Name of "B" Reader Address 19. Are you alleging a pulmonary impairment as the result of coal dust exposure? _____ yes ______ no If yes, attach results of pulmonary function studies and tracings. 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____. ______________________________ Plaintiffs Signature Subscribed and sworn to before me this day of 20 . ______________________________ Notary Public My Commission expires: __________ County: _______________________ Prepared and submitted by: _______________________________ Signature of Attorney for Plaintiff _______________________________ Name of Attorney (Print or Type) _______________________________ Street Address _______________________________ City/State/Zip Code __________________________ Telephone Number <<<<<<<<<********>>>>>>>>>>>>> 4 Instructions for Completion of Forms 101, 102, 102-CWP 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 (Plaintiffs Employment History) b. Form 105 (Plaintiffs 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-2s, paycheck stubs, etc. 2. All information must be
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