Kentucky > Workers Comp
Notice Of Claim Denial Or Acceptance (Occupational Disease) 111-OD - Kentucky
| Notice Of Claim Denial Or Acceptance (Occupational Disease) 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- OD 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 bent we 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 thounte am of compensation owed to the plaintiff. 3. This claim is denied for the following reasons: (a) Plaintiffs last injurious exposure to the risks of the occupational disease alleged did not occur in the employment of this defendant. Explain: (b) The plaintiff did not give due and timely notice to employer of the alleged occupational disease. Explain: (c) The claim is barred by limitations. Explain: (d) Plaintiff has not contracted the occupational disease alleged. Explain: Other reason for denial. Explain: 4. The plaintiffs average weekly wage at the time of the alleged exposure was $ . Completed AWW-1 to support this calculation iattachs ed. 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 This claim is covered by the Workers Compensation Act. Plaintiff was an employee of this defendant on the date alleged in the Application for Resolution of Claim. Plaintiff was exposed to the hazards of the disease during employment by more than one employer. Plaintiff has returned to work for this employer and is earning $______ per week.7. For alleged occupational diseases other than coal workers pneumoconiosis, descrietaibe il n d the physical requirements of plaintiffs job on the allegate oed df last exposure. 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 Number Subscribed 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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