Kentucky > Workers Comp
Application For Resolution Of Occupational Disease Claim 103 - 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 103 Adopted 1/ 1/97 KENTUCKY DEPARTMENT OF WORKERS CLAIMS Application for Resolution of Hearing Loss Claim Claim No. ___________________ vs. Plaintiff Defendant/Employer Social Security Number Street Address Birth Date City/State/Zip Code Street Address Insurance Carrier City/County Street Address State/Zip Code City/State/Zip Code Phone Number Alternate Phone Number Other Defendant Representative for Plaintiff Street Address Street Address City/State/Zip Code Reason for Joinder: City/State/Zip Code Phone Number FILED: Other Defendant Street Address City/State/Zip Code Reason for Joinder: Do Not Write In This Space <<<<<<<<<********>>>>>>>>>>>>> 2 I. Nature of Injury 1. Plaintiff states that on , he/she sustained or became disabled due to occupational hearing loss within the scope and course of employment with defendant employer at : (City/County/State) 2. State the date and means by which the plaintiff gave notice of injury to the employer: 3. Describe how the injury occurred: 4. Describe medical treatment, if any: 5. Name and address of physician whose report is attached: II. Personal Data 6. Highest grade completed in school: 7. GED awarded: __ ___ yes __ ___no 8. Professional or vocational degrees, certificates, or licenses: 9. Dependents: Name Social Security Number Relationship 10. Have you previously filed for or received workers compensation benefits? _ __yes _ __no If yes, give dates and nature of injury or disease: <<<<<<<<<********>>>>>>>>>>>>> 3 III. Employment Data 11. Type of work performed at date of injury: 12. Describe the physical requirements of plaintiffs customary job: 13. Weekly wage at date of injury: Attach copy of any proof of wages, such as paycheck stub, W-2, etc. 14. Has plaintiff returned to work? _ __ yes _ __no Name and address of current employer : 15. Weekly wage currently earned: . Attach copy of any proof of current wages. 16. A dispute exists between the parties as to: _ _ The defendant(s) liability for compensation _ _ The amount or duration of benefits _ _ Other (describe) Notice: Any person who knowingly and with intent to defraud any insuranc e company or other person files a statement or claim containing any materially false information or concea ls, 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 ap plication and in Form 104, 105, and 106 are true. This the day of 20 . ______________________________ Plaintiffs Signature Subscribed and sworn to before me this the day of 20 . ______________________________ Notary Public My Commission expires: __________ County: _____ ______ Prepared and submitted by: Signature/Representative for Plaintiff Title Address Phone Number <<<<<<<<<********>>>>>>>>>>>>> 4 Instructions for Completion of Forms 101, 102 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 typewritten. 3. File the original of this form and sufficient copies for all named defendants with the Department of Workers Claims, 1270 Louisville Road, Perimeter Park, Building C, Frankfort, Kentucky, 40601. 4. If you have no telephone number, please list a number at which you may be contacted. 5. If you have questions, call 1-800-554-8601 Form 102 - Application for Resolution of Occupational Disease Claim, and Form 103 - Application for Resolution of Hearing Loss 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 supporting the occupational disease e. Proof of Wages, including W-2s, paycheck stubs, etc. f. Social Security earnings record release form. 2. This form may be filed in combination with an Application for Resolution of Injury Claim (Form 101) if both benefits are sought. Information provided should be current through the date application is signed by plaintiff. 3. All information must be typewritten. 4. File the original of this form and sufficient copies for all named defendants with the Department of Workers Claims, 1270 Louisville Road, Perimeter Park, Building C, Frankfort, Kentucky, 40601. 5. If you have questions, call 1-800-554-8601 Note: Special attention should be given to stating the correct name and address of the employer and insurance carrier. Otherwise, claim processing may be delayed. Revised June, 2000
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