Kentucky > Workers Comp
Plaintiffs Employment History 104 - Kentucky
| Plaintiffs Employment History Form. This is a Kentucky form and can be used in Workers Comp . |
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FORM 104 ADOPTED January 1, 1997 KENTUCKY DEPARTMENT OF WORKERS CLAIMS PLAINTIFFS EMPLOYMENT HISTORY Name Social Security Number Name and Address Type of Industry Occupation Period of Exposure to substances of Employer Employment causing occupational (Begin with most recent employer) Begin date End date disease Month/Yr. Month/Yr (specify substance) 1. 2. 3. 4. 5. 6. 7. I hereby certify that the above information is true and correct to the best of my knowledge and belief. ____________________________________________ __________________________________________Plaintiffs Signature Date
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