Kentucky > Workers Comp
Application For Resolution Of Injury Claim 101 - Kentucky
| Application For Resolution Of Injury Claim Form. This is a Kentucky form and can be used in Workers Comp . |
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Form 101 KENTUCKY Adopted 6/00 DEPARTMENT OF WORKERS CLAIMS Application for Resolution of Injury 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 Injury1. Plaintiff states that on the day of 20 , he/she was injured within the scope and course of employment with defendant employer at:____________________ ________________________________________________________________________ (City/County/State)<<<<<<<<<********>>>>>>>>>>>>> 22. Describe how the injury occurred:____________________________________________ _______________________________________________________________________ _______________________________________________________________________3. Body part injured: ________________________________________________________4. State the date and means by which the plaintiff gave notice of injury to the employer: _______________________________________________________________________ _______________________________________________________________________5. Describe medical treatment, if any:___________________________________________ _______________________________________________________________________ _______________________________________________________________________6. Name and address of physician whose report is attached:__________________________ _______________________________________________________________________ II. Personal Data7. Name and address of last school attended: _____________________________________ _______________________________________________________________________8. Highest grade completed in school:____________9. GED awarded: _____ yes _____no 10. Professional or vocational degrees, certificates, or licenses:________________________ ________________________________________________________________________ ________________________________________________________________________11. Dependents: Name Date of Birth Social Security Number Relationship12. Have you previously filed for or received workers compensation benefits? ___yes ___no If yes, give Dept. of Workers Claims file number(s), dates and nature of injury or disease:_________________________________________________________________ _______________________________________________________________________ III. Employment Data<<<<<<<<<********>>>>>>>>>>>>> 313. Is plaintiff currently working? ______ yes ______ no 14. Type of work performed at date of injury:____________________________________________________________________________________________________________________15. Describe the physical requirements of job performed at date of injury:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________16. Weekly wage at date of injury: _________________. Attach copy of any proof of wages, such as paycheck stub, W-2, etc. 17. Weekly wage currently earned:_________ Attach copy of any proof of current wages.18. Name and address of current employer:_______________________________________________________________________________________________________________________ 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 106are true. This the day of 20 . ______________________________ Plaintiffs Signature Subscribed and sworn to before me this day of 20 . ______________________________ Notary PublicMy Commission expires: __________ County: ___________ Prepared and submitted by: Signature/Representative for Plaintiff Title Street Address _________________________________ City/State/Zip ________________________________ Telephone Number <<<<<<<<<********>>>>>>>>>>>>> 4 Instructions for Completion of Forms 101, 102 and 103 Form 101 - Application for Resolution of Injury Claim1. 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. Medic
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