Fill and Sign the Kentucky Department of Workers Claims Notice of Claim Form

Application fo r Resolution of a Claim – Occupational Disease October 2016 Edition Filed: KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS Application for Resolution of a Claim – Occupational Disease Claim No. vs. Plaintiff 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 Ad ditional Defendant Ad ditional Defendant Mailing Address Mailing Address City/State/Postal Code City/State/Postal Code Reason for Joinder: Reason for Joinder: I. Nature of Occupational Disease 1. Date and location of last exposure : Date of Last Exposure Location of Exposure (City/State/Postal Code) ☐ Plaintiff states that he/she became affected by reason of a disease arising out of and in the course of his/her employment . 2. Identify the occupational disease claimed : Nature of disease : 3. When and by what means did the plaintiff give notice of occupational disease to the employer? 4. Name and address of physician providing medical report : 5. Place of last exposure? City County State 6. Nature of the work in which the plaintiff was engaged at the time of exposure: 7. Will an interpreter be needed for the formal hearing? (Yes / No) If yes, in which language? 8 . Dependents Did the occupational disease result in death of claimant ? (Yes / No) If deceased, dependent information is required for a deceased worker. If work injury resulted in the death of claimant, attach/provide/upload Form F in addition to the application for Resolution of Claim. 9. 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: 10. If applying for retraining benefits, identify the training or education program in which the plaintiff is enrolled or plans t o enroll: Name: Street Address: City: State: Postal Code: Phone Number: 12a. Is plaintiff currently engaged in the severance or processing of coal? (Yes / No) 12b. Is plaintiff currently working in the industry in which the last exposure occurred? (Yes / No) 13 . Was there concurrent employment at the time of injury? (Yes / No) Concurrent Employer Name Concurrent Employer City Concurrent Employer State Postal Code 14 . Has the plaintiff returned to work? (Yes / No) 15 . Name and address of current employer and description of job currently being performed: Current Employer Name Current Employer City Current Employer State Postal Code Description of Job Performed: 16 . 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 Plaintiff Signature Instructions for Completion of – Application fo r Resolution of a Claim – Occupational Disease 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 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. Pro Se Submitters - 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.