Fill and Sign the Kentucky 103 Form

Application for Resolution of a Claim – Hearing Loss October 2016 Edition Filed: KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS Application for Resolution of a Claim – Hearing Loss Claim No. vs. Plaintiff/Employee Defendant/Employer (Business Name) Social Security Number/ Green Card Defendant/ Employer Mailing Address Birth Date Gender City/State/Postal Code Plaintiff Mailing Address Insurance Carrier City/State/Postal Code Insurance Carrier Mailing Address ☐ Outside United States City/State/Postal Code Country Plaintiff’s Phone Number Occupation Additional Defendants Additional Defendant Additional Defendant Mailing Address Mailing Address City/State/Postal Code City/State/Postal Code Reason for Joinder: Reason for Joinder: I. Nature of Occupational Hearing Loss 1. Date and Place of last exposure or accident resulting in hearing loss: Date of Last Exposure/Accident Place of Exposure/Accident (City/State/Postal Code) ☐ Plaintiff states that he/she became affected by reason of an exposure/accident arising out of and in the course of his/her employment. 2. Describe the nature of the occupational Hearing Loss: 3. When and by what means did the plaintiff/employee give notice of occupational hearing loss to the employer? 4. Name and address of physician providing medical report: 5. Nature of work in which the plaintiff/employee was engaged at the time of the occupationl noise exposure: 6. Will an interpreter be needed for the formal hearing? (Yes/No) If yes, in which language? 7. Have you previously filed for or received workers’ compensation benefits in Kentucky? (Yes / No) If yes, please provide the following information: Claim Number Date of Injury Nature of Injury/Disease Awards/Benefits If not a Kentucky claim, please provide the state in which you were awarded benefits: 8. Was there concurrent employment at the time of injury? (Yes / No) 9. Was the defendant/employer aware of your concurrent employement? (Yes / No) 10. Name and address of concurrent employer: Concurrent Employer Name: Concurrent Employer Address: Concurrent Employer City: Concurrent Employer State: Postal Code 11. Has the plaintiff/employee returned to work? (Yes / No) 12. Name and address of current employer and description of job currently being performed: Current Employer Name: Current Employer Address: Current Employer City: Current Employer State: Postal Code 13. Are you alleging a violation of a safety rule/regulation pursuant to KRS 342.165? (Yes / No) If yes, submit form SVC within 15 days after filing the Application for Resolution of Claim. Attestations: ☐ I understand that any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. ☐ Plaintiff herein being duly sworn, states that the statements in this application and in Form 104, 105, and 106 to be separately filed, are true. By entering your name below, you are confirming the accuracy of this form to the best of your knowledge. This form prepared and submitted by Relationship to injured worker Submitter Phone Number Submitter Email Address Instructions for Completion of – Application for Resolution of a Claim – Hearing Loss 1. All sections of this form must be completed, and the following shall be filed within 15 days: a. Form 104 (Plaintiff’s Employment History) b. Form 105 (Plaintiff’s Chronological Medical History) c. Form 106 (Medical Waiver and Consent) d. Medical report describing and supporting the occupational disease e. Proof of Wages, including W-2’s, paycheck stubs, etc. f. Social Security earnings record release form 2. All information must be typewritten 3. File the original of this form and sufficient copies for all named defendants with the Department of Workers’ Claims , Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky, 40601. 4. If you have no telephone number, please list a number at which you may be contacted. 5. If you have questions, call 1-800-554-8601. Note: Special attention should be given to stating the correct name and address of the employer and insurance carrier. Otherwise, claim processing may be delayed.