Fill and Sign the Claim Denial Form

Before Arbitrator      Claim Number                   Comes the defendant,       , as insured by       1 . 2. 3. (a) (b) (c) (d) The plaintiff's average weekly wage at the time of the alleged injury was $                               Notice of Claim Denial or Acceptance Form 111- OD Adopted 1/1/97 Filed : COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS CLAIMS NOTICE OF CLAIM DENIAL OR ACCEPTANCE Do Not Write In This Space Plaintiff/Employee VS. Defendant/Employer , and in response to the Application for Resolution of Claim, states as follows: This claim is accepted as compensable in its entirety. A settlement agreement will be filed. (Note: if claim is accepted, do not complete paragraphs 2 - 7). This claim is accepted as compensable, but there is a dispute concerning the amount of compensation owed to the plaintiff. This claim is denied for the following reasons: Plaintiff was not employed by defendant on the date of alleged injury. Explain: The alleged injury did not arise out of and in the course of employment. Explain: The plaintiff did not give due and timely notice to employer of the injury. Explain: The claim is barred by limitations. Explain: Other reason for denial. Explain: 4. Completed AWW- 1 to support this calculation is attached, if amount is different from plaintiff's application for resolution. 5. The following witnesses may present testimony relevant to denial of this claim. 1 . 2. 3. 4. This claim is covered by the Workers Compensation Act. Plaintiff has returned to work for this employer and is earning $       For the employer:                                           For the insurance                                           of my knowledge and belief. This the       day of                               Subscribed and sworn to before me this       day of             My commission expires:       County:                               6. The following are admitted by the employer: Yes No 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. per week. 7. For alleged occupational diseases other than coal workers' pneumoconiosis, describe in detail the physical requirements of plaintiff's job on the alleged date of last exposure. If an official job description exists, a copy must be attached. 8. The following persons have gathered information for completion of this form. Name Title Address: Street City State Zip Code Telephone Number carrier: Name Title Address: Street City State Zip Code Telephone NumberBeing duly sworn, the undersigned states that the statements in this form are true and correct to the best , 20 Signature Title Address Phone Number , 20 Notary Public Prepared and submitted by: Representative/Title Address Phone Number