Kentucky > Workers Comp
Application For Resolution Of Occupational Disease Claim 102 - Kentucky
| Application For Resolution Of Occupational Disease Claim Form. This is a Kentucky form and can be used in Workers Comp . |
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Form 102 Adopted 6/00 KENTUCKY DEPARTMENT OF WORKERS CLAIMS Application for Resolution of Occupational Disease 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 Disease1. Plaintiff states that on the ................................ day of .................................., 20.........., (day) (month) (year) he/she became affected by reason of a disease arising out of and in the course of his/or her employment. <<<<<<<<<********>>>>>>>>>>>>> 22. Identify the occupational disease(s) claimed: 3. State the date and means by which plaintiff gave notice of the injury to employer. 4. Place of last exposure (city) (county) (state)5. Nature of the work in which the plaintiff was engaged at the time of exposure 6. How did exposure to the disease occur? (Describe in detail) 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 Social Security Number Relationship12. Has plaintiff previously filed for or received workers compensation benefits? ___yes ___no If yes, give dates and nature of injury or disease: 13. If applying for retraining incentive benefits, identify the name, address, and phone number of the training or education program in which the plaintiff is enrolled or plans to<<<<<<<<<********>>>>>>>>>>>>> 3 enroll. 14. Is plaintiff currently engaged in the severance or processing of coal? ___yes ____no III. Employment Data 15. Type of work performed at date of occupational disease:__________________________16. Describe the physical requirements of plaintiffs customary job:_____________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________17. Weekly wage at date of occupational disease: _________________ Attach copy of any proof of wages, such as paycheck stub, W-2, etc. 18. Has plaintiff returned to work? ___ yes ___no Name and address of current employer :_______________________________________ ________________________________________________________________________ Is plaintiff still working in an environment where he/she is exposed to the hazards of the disease ? ____ yes ____ no Number of years of exposure to hazards of occupational disease Has plaintiff been exposed to the disease while working for more than one employer? ____ yes ____ no 19. Weekly wage currently earned:___________ Attach copy of any proof of current wages. 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 .<<<<<<<<<********>>>>>>>>>>>>> 4 ______________________________ Notary PublicMy Commission expires: __________ County: ___________ Prepared and submitted by: ________________________________ Signature/Representative for Plaintiff _________________________________ Title Street Address ________________________________ City/State/Zip Code Telephone Number <<<<<<<<<********>>>>>>>>>>>>> 5 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. 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 typewritten. 3. File the original of this for
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