Kentucky > Workers Comp
Motion To Substitute Party And Continue Benefits 11 - Kentucky
| Motion To Substitute Party And Continue Benefits Form. This is a Kentucky form and can be used in Workers Comp . |
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Form 11 KENTUCKY DEPARTMENT OF WORKERS CLAIMS Effective 10/6/2000 657 To Be Announced Avenue FRANKFORT KY 40601 Workers Compensation Claim no. __________________ Motion to Substitute Party and Continue Benefits Come now the undersigned, being all dependents of the deceased Plaintiff, __________________ and hereby move to be substituted as the Plaintiff herein for the purpose of receipt of benefits, and further state as follows: 1. Employee/Plaintiff:________________________________________________________________ 2. Date of death (attach copy of Death Certificate):__________________________________________ 3. Cause of death: ___________________________________________________________________ 4. Date of Award/Settlement and amount: ________________________________________________ 5. Date of Marriage (attach copy of Marriage Certificate): ___________________________________ 6. List of dependent(s) (attach copies of Birth Certificates): NAME SOCIAL DATE OF RELATION- ADDRESS (city, state, zip code) SECURITY NO. BIRTH SHIP Wherefore, the dependent(s) request that he/she (they) be substituted as the Plaintiff and that said benefits be paid directly to him/her (them). Respectfully submitted, ________________________________ (Signature) The undersigned hereby states that the foregoing is true and accurate to the best of my knowledge and belief. ________________________________ (Signature) Subscribed and sworn to before me by ______________________ on this __________ day of ____________________, 20____. ________________________________ Notary Public, Kentucky, State at Large My commission expires: ____________ I certify that copies were mailed this _________ day of ____________, 20______ to: Employer or Attorney for Employer: _________________________________________ Special Fund (if applicable): _______________________________________________ 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.
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