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Kentucky Department of Workers Claims Notice of Claim

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Application for Resolution of a Claim – Occupational Disease

KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS

Application for Resolution of a Claim – Occupational Disease

Claim No.

Filed:

Plaintiff

Defendant/Employer (Business Name)

Social Security Number / Green Card

Defendant/Employer Mailing Address

Birth Date

Gender

Plaintiff Mailing Address

City/State/Postal Code

City/State/Postal Code

Outside United States

Country

Insurance Carrier

Insurance Carrier Mailing Address

City/State/Postal Code

Plaintiff’s Phone Number

Occupation

Additional Defendants

Additional Defendant

Mailing Address

City/State/Postal Code

Reason for Joinder:

Additional Defendant

Mailing Address

City/State/Postal Code

Reason for Joinder:

I. Nature of Occupational Disease

1. Date and location of last exposure:

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:

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?

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:

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 to enroll:

Name:

Street Address:

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

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

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 for 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.

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What the Kentucky Department of Workers Claims Notice of Claim Is

The Kentucky Department of Workers Claims Notice of Claim is a formal document filed with the Kentucky Department of Workers' Claims to notify the agency and the employer that an injured worker intends to pursue a workers' compensation matter. It captures basic claimant and incident details, dates, employer identification, and a concise description of the injury or occupational disease. Filing the Notice initiates administrative processing, establishes the claimant on the agency's docket, and enables the schedule of hearings, mediator assignment, and employer response. Accuracy at submission reduces processing delays and dispute over jurisdiction or timeliness.

Why Filing a Proper Notice Matters

Timely and complete filing preserves the claimant's rights, starts the agency process, and triggers employer responsibilities under state workers' compensation procedures.

Why Filing a Proper Notice Matters

Who Prepares and Relies on the Notice

Typical preparers and recipients include claimants, employers, insurance carriers, and attorneys who handle workers' compensation matters.

  • Claimants or their representatives submit the form to activate a claim and request agency action.
  • Employers and insurers receive notice to investigate, file a response, and prepare wage and medical records.
  • Attorneys use the form to calendar deadlines and request hearings or mediation on behalf of clients.

Primary Signers and Their Roles

Claimant

An injured worker or authorized representative who reports injury details, signs to assert intent to pursue benefits, and provides contact information for case notifications and scheduling.

Employer/Carrier

The employer or its insurance carrier provides identification, claims handling contacts, and responds administratively; accurate employer data expedites medical and wage verification.

Essential Data Elements on the Notice

Claimant Name: Full legal name
Date of Injury: MM/DD/YYYY
Employer Name: Legal business name
Employer Address: Street, city, state, ZIP
Injury Description: Concise incident summary
Signature Block: Printed name and date

Consequences of an Incorrect or Late Notice

Lost Protections: Claims may be time-barred
Delayed Benefits: Medical payments may be postponed
Evidence Issues: Recording gaps or disputes
Filing Rejection: Form returned for corrections
Administrative Delay: Hearings deferred
Increased Costs: Litigation or attorney fees

Common Pitfalls to Avoid

  • Providing inconsistent claimant name or multiple spellings that create confusion during medical record retrieval and identity verification.
  • Using an incorrect injury date or failing to distinguish between a single accident and an occupational disease with cumulative onset.
  • Leaving employer or insurer contact fields blank, which slows verification and can delay medical authorizations and wage records.
  • Signing without authority or leaving signature/date fields incomplete, producing administrative rejections or requests for amendment.

Step-by-step: Completing the Notice of Claim

Follow these steps to complete the Kentucky Department of Workers Claims Notice of Claim accurately and consistently.

  • 01
    Gather Documents: Collect ID, medical reports, and employer contact details
  • 02
    Enter Dates: Use MM/DD/YYYY for injury and treatment dates
  • 03
    Describe Injury: Write a clear, concise factual description of the incident
  • 04
    Sign and Date: Claimant or authorized rep signs; include title or relation

What Happens After You File

Filing the Notice triggers a defined administrative workflow at the Kentucky Department of Workers' Claims and among involved parties.

  • Agency Intake: Notice recorded and docket number assigned
  • Employer Notification: Employer and insurer receive formal notice
  • Initial Response: Employer files response or acknowledges claim
  • Scheduling: Mediation or hearing set if dispute present

Key Components to Include for a Professional Notice

A complete Notice of Claim presents clear identity data, a factual injury narrative, precise dates, and signer authentication to avoid administrative delays.

Claimant Identity

List full legal name, date of birth if required, telephone and mailing address so the agency can serve notices and schedule hearings accurately.

Incident Details

Provide a concise factual account of how the injury occurred, location, and immediate treatment to establish the basis for benefit requests.

Exposure Window

For occupational disease claims, specify the period of exposure or cumulative onset rather than a single date to clarify claim scope.

Employer Contact

Include the employer's formal name, mailing address, and insurance carrier to enable timely verification and payment routing.

Medical Providers

Identify treating providers and dates of first treatment to support medical causation and initial benefit determinations.

Signature and Authority

The claimant or authorized representative must sign and date; include printed name, relationship, and contact for follow up.

Configuring an Electronic Submission Workflow

If you submit electronically, configure fields and notifications to mirror the paper form and preserve audit details.

Field Configuration
Claimant Name Required text field, auto-validated
Date of Injury Date picker, MM/DD/YYYY
Employer Details Grouped address fields, required
Signature eSignature field with timestamp

Digital Submission: Platform Considerations

Electronic filing requires a platform that preserves an audit trail, supports required fields, and secures personal information.

  • Document Formats: PDF, DOCX supported
  • Security: TLS and AES-256 encryption
  • Authentication: Email or multi-factor options

Timing Expectations and Filing Windows

Deadlines and timing for workers' compensation claims vary by jurisdiction and claim type; submit as soon as possible after injury to avoid timeliness disputes.

Immediate Employer Notice:

Notify employer per company policy to document the event

Agency Filing:

File with the Department of Workers' Claims as directed by agency rules

Medical Treatment:

Seek and document first medical care promptly to support causation

Hearing Scheduling:

Expect scheduling after employer response and prehearing steps

Statute of Limitations:

Timeliness rules apply; verify state procedures before filing

Key Processing Milestones in Sequence

These milestones show common administrative stages from notice to resolution that occur after filing the Notice of Claim.

01

Notice Filed

Agency records the claim and assigns a docket number

02

Employer Response

Employer/insurer files a formal response or denial

03

Prehearing Steps

Mediations, disclosures, and scheduling orders occur

04

Final Disposition

Settlement, hearing decision, or administrative closure

Sample eSignature Provider Comparison for Filing and eSubmission

Common eSignature platforms differ by price, bulk sending, and compliance features; signNow is shown first for comparison against common alternatives.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Illustrative Filing Scenarios

These short examples show common notice uses and outcomes to help you prepare a complete filing.

Construction Site Injury

A laborer filed the Notice after an on-site fall that required immediate care and follow-up.

  • Employer provided wage records promptly to the agency.
  • The clear chronology and attached medical reports enabled quicker case triage, earlier mediation scheduling, and reduced administrative questions about timeliness.

Occupational Disease Claim

An employee reported progressive respiratory symptoms with long-term exposure.

  • The claimant supplied exposure dates and provider notes.
  • Detailed exposure windows and provider documentation helped the agency classify the claim properly and avoid repeated information requests that delay adjudication.

Practical Tips for Accurate and Efficient Filing

Use standardized templates, confirm employer identifiers, and keep supporting documents organized to minimize processing time and follow-up requests.

Use Clear Language
Draft the injury description in straightforward factual terms, avoiding legal conclusions; clarity reduces investigator follow-up and helps the agency assess compensability swiftly.
Attach Key Records
Include initial treatment reports, first notice to employer, and any witness contact information to substantiate the claim and speed verification.
Keep Copies
Retain signed copies and any submission receipts or audit certificates to demonstrate filing and to support appeals if needed.
Confirm Contact Info
Provide current telephone and mailing details for fast communication and to ensure hearing notices reach the parties without delay.

Frequently Asked Questions

Answers to common questions about completing, signing, and submitting the Kentucky Department of Workers Claims Notice of Claim.


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