Kentucky > Workers Comp
Notice Of Claim Denial Or Acceptance (Injury And Hearing Loss) 111 - Kentucky
| Notice Of Claim Denial Or Acceptance (Injury And Hearing Loss) Form. This is a Kentucky form and can be used in Workers Comp . |
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Notice of Claim Denial or Acceptance Form 111- Injury and Hearing Loss Filed: Adopte d 1/1/97 COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS CLAIMS Before Arbitrator Claim Number NOTICE OF CLAIM DENIAL OR ACCEPTANCE Do Not Write In This Space Plaintiff/Employee vs. Defendant/Employer Comes the defendant, , as insured by , and inresponse to the Applcatii on for Resolution of Claim, states as follows: 1.This claim is accepted as compensable in its entirety. A settlement agreemill benet w filed. (Note: if claim is accepted, do not complete paragraphs 2 - 7). 2.This claim is accepted as compensable, but there is a dispute concerning the amount of compensation owed to the plaintiff. 3.This claim is denied for the following reasons: (a) Plaintiff was not employed by defendant on the date of allegury.ed inj Explain: (b) The alleged injury did not arise out of and in the course of employment. Explain: (c) The plaintiff did not give due and timely notice to employer of the injury. Explain: (d) The claim is barred by limitations. Explain: Other reason for denial. Explain: 4. The plaintiffs average weekly wage at the time of the alleged injury was $ . Completed AWW-1 to support this calculation iattachs ed, if amount is different from plaintiffs applicationfor re solution. 5. The following witnesses may present testimony relevant to denial of this claim. 1. 2. 3. 4. <<<<<<<<<********>>>>>>>>>>>>> 26. The following are admitted by the employer: Yes No Plaintiffs injury was covered under the Workers Compensation Act. The injury occurred or ecab me disabling on____________, 200___ Date Plaintiff gave due and timely notice of the injury. Plaintiff has returned to work for this employer and is earning $_______ per week. Temporary total disailitb y income benefits were paid as the result of thury.e inj All known medical expenses have been paid as the result of the injury. 7. Describe in detail the physical requirements of plaintiffs job at the time of the alleged injury. If an official job description exists, a copy must beattach ed. 8. The following persons have gathered information for completion of this form. For the employer: Name Title Address: Street City State Zip Code ( ) Telephone Number For the insurance carrier: Name Title Address: Street City State Zip Code ( ) Telephone Number Being duly sworn, the undersignetatesd s that the statements in thformis are true and correct to the bestof my knowledge and belief. This the day of , 200 . Signature Title Address Phone NumberSubscribed and sworn to before me this day of , 200 My commission expires: County: Notary Public Prepared and submitted by: Representative/Title Address Phone Number
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