Application For Resolution Of A Claim Injury {101}

APPLICATION FOR RESOLUTION OF A CLAIM - INJURY. This Kentucky Department of Workers’ Claims form (rev. February 2020) is used to initiate and process workers’ compensation claims for workplace injuries. It collects identifying information for the plaintiff, employer, insurance carrier, and any additional parties. Claimants must report the date, location, and cause of the injury, body parts affected, medical treatment received, and the treating physician’s details. The form also requests dependent information (and Form F in the event of a worker’s death), prior workers’ compensation history, and concurrent employment details. Claimants must indicate if they have returned to work, current job duties, and educational or vocational background. Allegations of safety rule violations under KRS 342.165 must be supported with Form SVC. A declaration at the end warns against fraudulent filings. www.FormsWorkflow.com